In the last decade, an increasing number of donors are withdrawing their support for healthcare. This has been especially true for middle-income countries, where the growth of domestic resources was one of the triggers for donor funding reduction. The Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) has termed this process as “transition”, although the terms such as “graduation” (USAID terminology), “sustainability” and “self-reliance” are also used.

Development Assistance for Health (DAH) is decreasing, including for HIV/AIDS. In the Eastern Europe and Central Asia (EECA) region, DAH has decreased by 33% from 2010 to 2017, resulting in the withdrawal of over US$64 million from HIV/AIDS programs . This has created pressure on national ¹ budgets and has resulted in a significant gap in HIV/AIDS funding in low- and middle-income countries where overall growth of a country’s Gross National Income (GNI) has not been accompanied with an equivalent increase in public allocations for health and social services, especially for interventions that target key affected populations.

The Global Fund remains the largest multilateral donor in the field of HIV/AIDS, especially in Europe. From 2003 to-date, it has invested over US $2,573 million in the EECA region, out of which US$1,431 million has been for HIV/AIDS .

Sustainability Bridge Funding (SBF) is an idea that has been discussed among donors and civil society organizations (CSO’s) as a way of mitigating the negative effects of transition and in providing support for key essential services for communities and key populations. As a safety net mechanism, it should respond to gaps in funding and mitigate adverse effects of donor funding withdrawal. Nevertheless, very few donors have provided this type of targeted donor support for countries losing Global Fund support. Open Society Foundations (OSF) first piloted the idea of SBF in Southeastern Europe — a region where the withdrawal of Global Fund has led to the collapse of services in countries including Romania, Bosnia and Herzegovina and Serbia — by supporting civil society to navigate the transition process and engage in effective budget advocacy.

Building on this work, in 2018 OSF, through the Eurasian Harm Reduction Association (EHRA), initiated the project, Budget Advocacy and Monitoring in countries of South East Europe³. It provided funding to three transitioning countries in the Balkan region – Bosnia and Herzegovina (BiH), Montenegro, and Serbia — through the sub-regional network organization, Drug Policy Network South East Europe (DPNSEE), to support budget advocacy for harm reduction services.

This case study looks at the implementation of this project as one of the demonstrations of the SBF mechanism, with the objectives to:

  • Document the SBF pilot in 3 Balkan countries and to analyze the strengths and weaknesses of this approach and to develop suggestions for improvement; and, Document the results, successes, and 
  • Document the challenges of the budget advocacy projects supported through the SBF approach.

Interviews were recorded between April and July 2019. During the development of this case study, project implementation was not completed, although it was at an advanced stage, allowing for the interpretation of results.