Author: Ivan Varentsov

The economic growth of developing countries coupled with the slow recovery of developed (donor) countries after the recent economic crisis has changed traditional development assistance models. As a result, in recent years a clear tendency has been observed in a decrease of funding available from international and bilateral donors to middle income countries (MICs) for health-related responses, including for HIV and TB programs, and the Global Fund is no exception. Consequently, there is a widespread concern as to how to ensure the successful transition from Global Fund support of HIV and TB responses to national funding in MICs and the sustainability of such programs, especially those targeted at KAPs. The majority of countries transitioning from donors‘ support have certain mechanisms for government support of NGOs working in a social sphere. But in most cases such mechanisms are not applicable for support of HIV/TB prevention services targeted on KAPs. This problem among another issues related to the so called „social contracting mechanisms“ was discussed at a „Global consultation on social contracting: working toward sustainable responses to HIV, TB, and malaria through government financing of programs implemented by civil society“ convened by the Open Society Foundations, the United Nations Development Programme, and The Global Fund to Fight AIDS, Tuberculosis and Malaria, which took place at the beginning of October 2017 in New York (USA). A case of Montenegro as the country with a positive and to some extent pioneering experience in developing enabling environment for social contracting in a short time period due to the joint efforts of all key stakeholders involved: government, donors, technical partners and civil society, was presented at that consultation. We decided to study this case more precisely.

Brief overview of HIV epidemiological situation in county and the history of Montenegro‘s eligibility for the Global Fund‘s HIV related support

Montenegro is a low HIV prevalence rate country (0.02%) with a population of about 623 thousand people facing challenges with possible growth in concentrated epidemic, especially among population of MSM. According to the Institute of Public Health (presentation at the National HIV/AIDS Conference, March 2017) 228 HIV positive people were registered in Montenegro since 1989, which is approximately 50% of the estimated total number. According to the 2015 HIV/AIDS Report by the Montenegrin Institute of Public Health the prevailing mode of transmission of HIV in Montenegro is unprotected sex (85%), and retains this increasing trend since the beginning of the epidemic. Parenteral way of HIV transmission still remains very rare – only 4% of all registered HIV cases, out of which 1% were infected inside medical institutions outside of Montenegro, and 3% due to the sharing of contaminated injecting equipment. According to the data from the Institute of Public Health zero new infections among people who inject drugs were diagnosed since 2012.

By now the total Global Fund HIV related investment in Montenegro is US$8,765,158.  This includes Round 5 grant started in 2006 and Round 9 grant started in 2010. The implementation of both grants came to an end by June 2015 while the support of the work of CCM was ensured for two following years.

After introduction by the Global Fund in 2011 of the new eligibility criteria Montenegro – being classified as a UMIC with a low disease burden – became one of the countries ineligible for further Global Fund HIV suppor and zero funding was allocated for the country in 2014 when the New Funding Model was introduced. However in 2016, Montenegro’s HIV disease burden categorization changed from ‘Moderate’ to ‘High’ based on the data from the 2014 integrated bio-behavioral survey that showed the increased disease burden among MSM and in accordance with the Global Fund Board’s decision in November 2016 on the allocation of resources for the 2017-2019 allocation period, Montenegro has been allocated €556,938 for HIV. According to the Allocation letter sent by the Global Fund Secretariat to Montenegrin CCM in December 2016 one of the conditions for accessing by the country of the full allocation amount is that “the 2017-2019 allocation amount is dependent on the functionality, in form and substance acceptable to the Global Fund, of a social contracting mechanism for engagement of non-governmental organizations, through which the Montenegro governmental institution(s) and the Global Fund will finance HIV prevention, care and support activities”. “Montenegro’s re-eligibility for Global Fund financing is an opportunity to learn from the dynamic of the epidemic and to catalyze sustainable government funding for key and vulnerable population services, while developing a stable mechanism for operationalizing those funds. We expect that the funding request to the Global Fund will build on this country mechanism”, says Gyongyver Jakab, the Global Fund Portfolio Manager, EECA.

Consequences of termination of Global Fund support in 2015

According to the case study on transition processes in Montenegro (EHRN, 2016), although after the end of the Round 9 HIV grant the government did absorb a significant part of the HIV treatment, diagnostic and OST services, as well as continued to fund general prevention, and also the buffer stock of prevention commodities (e.g. needles and syringes), procured under the Global Fund financed Round 9 grant, enabled the NGOs to continue to some extent service delivery – after June 2015 HIV prevention programs being implemented by NGOs and focused on KAPs have been significantly reduced to a minimum due to the lack of funding. For example, by the middle of 2016 two of three NSPs – in Podgorica and Bar – operated by two local harm reduction focused NGOs CAZAS and Juventas were forcedly closed until the first available funding opportunity.

The only funding to support the prevention services was available at a national level through the Commission on Allocation of Games on Chance Revenue, but it was not sufficient to provide comprehensive services to any of the key affected populations. According to the OSF case study draft on the transition processes in Montenegro (on file with the author) the 2016 disbursements through the National Lottery/Games of Chance Fund covered approximately one-third of what Global Fund had previously contributed for MSM interventions, and one-quarter of the support which had been received for prison-based prevention programs. Programs targeting sex workers received lottery funds for the first time in 2017, but at a rate of only 13% of previous Global Fund funding, says the report. The decrease of funding available also affected the coverage of clients by the prevention services: according to OSF case study draft Juventas experienced almost 50% decrease in reach of unique MSM clients in the first half of 2017, in comparison to the same period in 2015. The need for new sources of funding for HIV prevention programs in Montenegro was evident.

New funding opportunities for HIV prevention in Montenegro and related challenges

According to EHRN case study, as a result of a strong advocacy activity of local civil society representatives and NGOs, Juventas in particular, at the end of 2015 the Parliament of Montenegro adopted the Law on the Budget of Montenegro for 2016, accepting the amendment submitted by the members of a political party Pozitivna. This amendment allowed for the first time the allocation of funds (€100,000) specifically for, ‘non-governmental organizations who provide services for support to people living with HIV/AIDS and affected populations’.

Although this decision was made at the end of 2015 the actual open call for applications for this funding was announced only on the last week of December 2016.  According to Vladan Golubovic, Secretary of the Montenegrin CCM, such delay had multiple reasons – starting with the unstable political situation and elections of the new government at that year, change of 3 Directors in one year of the National Health Insurance Fund which was supposed to become the main source of funding for such support of NGOs activities and also unclarity on the particular funding mechanism and procedures to be used.

Finally, the mechanism and procedures were arranged and agreed between the Ministry of Finance, Ministry of Health, Institute for Public Health and National Health Insurance Fund, as well as the budget rebalanced and it was the Institute for Public Health who announced the call and organized the process. The mechanism used for disbursement of these funds in the equivalent of €100,000 was public tender announced in accordance with the Montenegrin Law on Public Procurement but only NGOs were eligible to apply. The contracts with 3 NGO winners – Juventas, CAZAS and Montenegrin HIV Foundation – were signed at the end of February and the funds were disbursed at the beginning of March 2017. Juventas and CAZAS got funding for provision of institutional support for drop in centers for IDUs and sex workers, and delivery of outreach harm reduction services among IDUs, MSM and Roma population. Montenegro HIV Foundation was responsible for the component of providing psychosocial support to people living with HIV.

Development of the new social contracting mechanism

Although the distribution of the allocated funding to NGOs through the public tender went successfully it became clear that this mechanism for a number of reasons is more applicable for the private sector organizations rather than for NGOs, says Vladan Golubovic. According to Mr. Golubovic, the rough requirements for the application documentation and its volumer, requirement to provide a bank guarantee which was one of the key challenges faced by NGOs within the application process, impossibility to purchase by NGOs the needed medical commodities including syringes and needles – all that evidentiated the need to develop another mechanism, more accessible and low threshold for NGOs taking into account that another 100k were allocated under the Ministry of Health budget for 2017 to support HIV prevention services among KAPs through NGOs. The condition of the Global Fund for accessing by the country of the new funding also played its role in this decision.

In September 2017 a working group was established under the CCM to coordinate the process of development of the sustainable social contracting mechanism. According its ToR (on file with the author) the members of CCM working group are representatives of the following institutions/organizations: Ministry of Health, Institute for Public Health, National Health Insurance Fund and NGOs Juventas and CAZAS. Among the expected deliverables from this group are:

• defining the needs and scope of services for calls for proposals;
• developing clear procedures and guidelines on social contracting for provision of HIV services (the package of the 14 documents altogether);
• conducting a detailed legal assessment and analysis of the environment to support government contracting of NGOs to implement HIV treatment, care and/or prevention activities in Montenegro, and detailed recommendations to address potential barriers; and
• defining quality standards for service provision; minimal and optimal services and coverage packages; and costs for NGOs to provide the services.

 “It is expected that the working group should complete its work in early November. The results of the working group should be approved by the CCM and adopted by MoH. The mechanism should be put in operation by the end of this year including the contracts to be signed and money to be distributed before the end of December otherwise the funding allocated for these purposes for 2017 could be lost”, – says Ivana Vujovic, the Executive Director of NGO Juventas.

The work of the working group is being supported by the Global Fund through the CCM Funding project. To complete all these tasks the technical assistance is being provided to CCM and the working group: earlier in May this year two NGOs, Juventas and CAZAS, received funding from the Open Society Foundations to support the process of development of this new social contracting mechanism. Juventas is being responsible for managing the development of the rules and procedures of the NGO contracting mechanism including the call for proposals and contracts (on file with the author), and CAZAS is focused on building the capacity of NGOs and government agencies to participate and manage social contracting including the organization of the capacity building workshop, study tour to Estonia to study best practices, etc. The experience of the implementation of the social contracting mechanisms in Croatia is being analyzed and used within this process with the involvement of the relevant Croatian experts. Another part of technical assistance is coming through the UNDP Istanbul Regional Hub in a form of consultant who is responsible for the legal assessment and analysis of the environment to support government contracting of NGOs to provide HIV services. “The positive developments we have been seeing in Montenegro over the last year are a reflection of the extraordinary commitment and collaboration of government and civil society stakeholders in the country. We have been privileged to work in partnership with OSF and UNDP in supporting these ground-breaking efforts”, – says Gyongyver Jakab.

Another recent development related to the work of NGOs in Montenegro is the adoption of the new version of the NGO Law in summer this year. One of the implications of this new version of law is that the funding through the Lottery Fund will not be available for NGOs anymore. According to Mr. Golubovic this mechanism was not very effective as it was functioning on the basic principle that everyone who fulfils the criteria of the call gets a small piece of the funding available. From the experiences of local NGOs, fully requested amounts have never been received by NGOs, it was always not more then 25 – 30 % of the requested amount to be granted. In 2015, approximately 25% of the total planned budget for the NSP was covered by this fund (only fees for outreach workers and other staff, as well as their additional training) which was not enough and required further actions by the relevant decision makers, especially the Ministry of Health (EHRN case study, 2016).

But the key change to be brought by the new law is the decentralized funding of NGOs on the national level which means that now each Ministry could allocate a certain budget to support NGO activities in the priority areas, says Ms. Vujovic. For that purpose, the Ministry should each year make the “sectoral analysis” to identify the priority areas to be covered. According to Vladan Golubovic this analysis should be the main instrument for the Ministries to request the financial support from the Ministry of Finances which makes a decision on the final allocations to each Ministry for the next year. Such decentralization approach was also adopted from the Croatian experience. For the MoH such “sectoral analysis” for HIV\AIDS area was done by the CCM Secretariat this year. “The planned budget for 2018 to support HIV prevention services among KAPs through NGOs is about 300 000 EUR if to matching funds to become available from the Global Fund for that year which is 3 times bigger than in the previous two years. This law also provides more security for a long-term sustainability, as Law on NGOs prescribes that 0,3% of National budget has to be used for funding NGOs’ projects (plus additional 0,1% is dedicated to protecting of people with disabilities, and 0,1% for co-funding EU funded projects)”, – says Ivana Vujovic. The only problem, according to both experts is that this new version of the NGO Law will come fully into a force only starting from 1st of January 2018. So, it is not clear yet if it will be the Ministry of Health to announce the open call for proposals or some other institution. There is an opinion that most likely it cannot be and will not be published by MoH this year.

“This is a great example of multisectoral cooperation in order to ensure the continuation of HIV prevention services for most at risk populations in country”, – says Vladan Golubovic. “All the parties involved – from the Global Fund, OSF, UNDP and CCM to the governmental structures and NGOs – each of them has their specific role. I believe it Is the best way to succeed for such work, you just have to go jointly, you have to go together, find appropriate allies and success is guaranteed”.

“This social contracting mechanism we are developing now – it will allow us to have a sustainable system of NGO funding in place and not to be dependent on any personalities in the government. This should allow NGOs to do their work every year without any interruptions”, – says Ivana Vujovic.

“The Government of Montenegro understands the need to ensure the access for key affected by HIV populations to the prevention services and the important role of NGOs in provision of such services. That is why Ministry of Health is fully supportive to the development of the appropriate social contracting mechanism to become a sustainable and long term solution for ensuring the provision by NGOs of HIV prevention services to KAPs in Montenegro.  Such progress on that matter within a short time became possible also due to the support provided by the Global Fund Secretariat and OSF as well as due to the active involvement of local NGOs into these processes“, – says Nikola Antovic, the Secretary of the Ministry of Health of Montenegro.

This article is the authors original version of the one published at Aidspan earlier this month