When it comes to HIV and health services, social returns on investment matter

Posted December 1, 2021

Counseling services in a mobile services unit in North Macedonia. Photo: HERA

Despite battling the HIV epidemic for decades, the fight is far from over.

In fact, according to UNAIDS, Eastern Europe and Central Asia is one of only three regions where the HIV epidemic is growing. Since 2020, new HIV infections have increased by 72 percent and AIDS-related deaths by 24 percent. Certain populations - people who use drugs, sex workers, men who have sex with men, prisoners - and their sexual partners are disproportionately impacted, accounting for 99 percent of the new HIV infections in 2019. And data suggests that just about half (or less) of people living with HIV are receiving antiretroviral treatment.

More action is needed to halt the spread of the epidemic as well as to address inequities in accessing prevention, treatment and care services among key and marginalized populations. And the most successful action can be done at the ground level.

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. In these cases, the government pays an NGO for services rendered and the NGO provides agreed deliverables in exchange.

There are four conditions that are sine-qua non for effective social contracting mechanisms:

1.     existence of legal and administrative systems permitting and facilitating social contracting

2.     strong national leadership and funding from national authorities

3.     allocating budget resources for HIV and TB-specific activities coupled with transparency, fairness and effectiveness in funding allocations

4.     technical, managerial capacity and governance mechanism 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 limited capacity of the region’s NGOs to participate in public procurement processes.

Significant returns on investment

Social contracting arrangements contribute to the financial sustainability of HIV services, but they can also have a significant social return on investment.

Historically, cost-effectiveness or cost-benefit analysis have been used in demonstrating the so-called “value for money”. The drawback of these concepts is they only focus on the monetary or economic value-added created by an activity.

However, there may be additional, indirect and non-monetary benefits to be seen (e.g. wider community/societal benefits, improvement in health, etc). Determining this wider set of benefits created by a project or activity and monetizing their value (by directly involving the beneficiaries of an activity) is the essence of the Social Return On Investment (SROI) methodology.

We adapted this SROI methodology to the context of HIV in this region – using four case studies across three countries. The case studies mostly revolve around providing two types of activities: counselling services to key populations as well as help to people living with HIV.

In Bosnia and Herzegovina, we looked at the provision of  HIV counselling to key populations at higher risk of HIV, as well as support to people living with HIV through various social measures (e.g., provision of  food and personal hygiene products). In North Macedonia, we assessed mobile testing and counselling of key marginalized and key populations in the country, including young people. The Belorussian Red Cross case study focused on provision of free testing and prevention activities for key populations and the provision of palliative care to people living with HIV, as well as additional services (such as distribution of free condoms and syringes). Finally, the Belarus Pozitivnoe Dvizhenie case encompassed ensuring access to antiretroviral treatment in two areas (Minsk and Gomel).

From these, we drew a few broad conclusions:

1) There are indeed significant social returns realized as a result of the implementation of the activities by NGOs. 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. Counselling (and thus improving knowledge about potential modes of transmission) averts a significant number of infections, while also improving the overall wellbeing of marginalized communities. Monetary and psycho-social support to people living with HIV improves both their physical and mental health, thus increasing their likelihood to seek and find employment and strengthen their material wellbeing. 

2) The results obtained by applying the SROI methodology are strong enough even considering changes in assumptions: Adjusting for drop off rates (how long the benefits will last and how fast or slow they would wane) and attribution rates (what extent the results of the SROI should be 'discounted' by other agents/channels that might have contributed to improvements) still yields robust results.

3) Despite country heterogeneity, the SROIs are broadly comparable. Although our sample includes countries from different sub-regions from the wider Europe and Central Asia region, our findings are similar, mostly driven by the nature and the types of activities that were implemented.

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, and reduce the barriers hindering its execution.  

It could provide a systematic framework for planning, monitoring and evaluation of a particular activity or project conceived and executed by an NGO. Moreover, it can demonstrate the value for money of an activity or a project, particularly important given the numerous competing interests for governmental resources.

Through its participatory engagement methods, SROI analysis can help capture outcomes typically hard to capture, such as self-confidence or empowerment, which is particularly relevant in the context of people living with HIV, key populations and marginalized groups.

Finally, and most importantly, given the lack of political capital among these groups, providing the social returns of investment of NGO-delivered activities could be ‘protective’ in the face of political pressure or when under budgetary scrutiny.

Social contracting is a key element for sustainability of HIV and health services, NGO funding and overall social protection. Funds and financial allocations from various sources for health and HIV continue to be limited, and SROI is a good contribution to the argument for increased investments in this innovative financing approach.