Failure to Fund: New Research from Harm Reduction International

FCAA’s recent resource tracking report found that funding for the majority of key populations had significantly decreased from 2018 to 2019, including a 31% decrease for people who inject drugs. In this guest blog, we invited Catherine Cook, Sustainable Financing Lead, Harm Reduction International, to expand on this funding gap, as well as to share findings from their new report: Failure to Fund: The continued crisis for harm reduction funding in low- and middle-income countries.

Can you share some key findings from the report?

The main headline from our research is that the funding crisis for harm reduction in low- and middle-income (LMI) countries appears to be more pronounced than ever. After having remained unchanged for the previous decade, we found funding for harm reduction in LMI countries to be 30% lower in 2019 than in 2016.

Overall, we identified US$ 131 million for harm reduction in 2019 – only 5% of the US$ 2.7 billion UNAIDS estimates is required annually by 2025 for an effective HIV response among people who inject drugs. This represents a staggering 95% funding gap and a threat to the overall HIV response.

A second key finding is that the split between international donor and domestic funding for harm reduction is almost equal. We found more domestic funding for harm reduction and in more countries than in our previous research. This seems positive but may be a reflection of more data becoming available rather than a real increase. More broadly, given the widening funding gap, this finding could point to decreases in international donor funding outpacing any increases in domestic funding for harm reduction.

A third key finding is that harm reduction in LMI countries is still very reliant on funding from international donors. Among the ten international donors providing support, the largest shares were provided by the Global Fund (60%), PEPFAR (12%) and Open Society Foundations (10%). The data showed a considerable drop in international donor funding from the levels found for 2016, but changes in the way the Global Fund and PEPFAR record their financial data make it challenging to determine the true extent of this reduction.

What have the reactions been to this report? What do you hope some next steps might be? How do these findings align with other stakeholder responses?

The general reaction has been that this is a shocking funding gap. It chimes with Aidsfonds Fast Track or Off-Track report from 2020 which highlighted the poor funding for key population programming more broadly. People have also reflected that it’s timely research, given the emphasis on HIV prevention in the 2021 – 2026 Global AIDS Strategy and the imminent adoption of a new Political Declaration on HIV. We hope that the findings bring increased attention to the marginalization of people who use drugs, including within the HIV response. We’d like it to be the trigger for dialogue on how to increase the overall funding for harm reduction, as well as how to do better with what we have. In the report we give some ideas on this.

For example, communication and coordination between international donors would help ensure investments are strategic and complementary. Close tracking of funding they provide (including over time) would need be part of this.

The report also highlights the particular problem of transition for harm reduction and the need for a continuing international donor role. Where punitive environments make transition unlikely, international donors will continue needed to protect the rights and health of people who use drugs. But even where transition is possible, advocacy and policy reform will be needed to ensure domestic funds support quality, person-centred harm reduction, delivered by civil society and community-led organisations.

Another call we make in the report is for international harm reduction donors to use their influence among donor circles to bring other donors to harm reduction, including those in adjacent sectors such as health, development, gender, criminal justice and human rights. Several already do this, but the power of the donor voice cannot be understated.

On the day of publication, we are excited to be bringing together international donors, leaders in harm reduction and HIV to consider strategies for coordinated action to improve the funding situation for harm reduction.

What role has the COVID-19 played on implementing and funding global harm reduction efforts?

The pandemic has had a major impact on harm reduction implementation around the world. Serious disruptions to harm reduction service delivery have been reported in all regions. Most recently, we heard that a Global Fund survey of 38 countries found that services for sex workers and people who inject drugs had been reduced by 20%. COVID-19 also poses a very real threat to the already precarious funding situation for harm reduction in many LMI countries. There have been many calls to protect against the diversion of focus and funds towards COVID-19 at the expense of lifesaving services for already marginalized populations.

One positive has been the expansion of take-home provision of opioid agonist therapies in forty-seven countries, which has been long called for by advocates. Community responses have been the driving force during the pandemic. But we know that community-based and community-led organizations are often not the recipients of harm reduction funding. Our research found that 7% of harm reduction funding from international donors goes to community-based organizations, not all of which are community-led. The Robert Carr Fund stands out as an international donor mechanism geared up to support community advocacy, providing all-important core funding and a flexible approach that allows advocacy plans to pivot in response to situational demands.

Private philanthropy represents just 2% of total resources for HIV in LMIC – what role can our sector play?

Philanthropic donors already play a crucial role, particularly in funding harm reduction advocacy. Open Society Foundations provided 10% of international donor funding for harm reduction in 2019, through support for services, advocacy and legal and policy reform initiatives to create an enabling environment for harm reduction. The Elton John AIDS Foundation and ViiV Healthcare’s Positive Action also provide crucial support.

Having said that, support for harm reduction among philanthropic donors could be much greater. Just 1% of private philanthropy for HIV in LMI countries went to harm reduction in 2019[1]. When we consider that there’s a 30% shortfall in funding for the HIV response overall, but a 95% shortfall for harm reduction, all donors contributing to the HIV response could help to redress that balance.

What would you like HIV-informed funders to most take away from this report?

The main takeaway message is that the staggering shortfall in funding for harm reduction is a threat to the global HIV response. We can’t end AIDS and TB, eliminate hepatitis C or achieve Universal Health Coverage by 2030 without the leadership of people who use drugs and a fully funded harm reduction response.

There is a danger with such a shocking funding shortfall that it seems impossible to solve, particularly when political will is such a key factor. While there is a clear need for funding for services, funders can have a catalytic impact through relatively modest investments in harm reduction advocacy. Strong civil society and community-led advocacy can bring about legal and policy change, as well as the political and financial support needed for a sustainable harm reduction response.

[1] FCAA’s 2019 report, Philanthropic Support to Address HIV/AIDS, tracked $14.8 million to People who inject drugs, accounting for 2% of global HIV philanthropy. This discrepancy was due to the inclusion of high-income countries in FCAA’s research, along with slight variations in the data sets, taxonomies, and methodologies.