AIDS 2004, Bangkok: a human rights and development issue.

THE 15th International AIDS Conference in Bangkok from 11-16 July 2004 once again brought together the wide range of actors involved in fighting the HIV/AIDS epidemic. Researchers, scientists, donors, government leaders, public health officials, doctors, pharmaceutical and representatives and religious-based organisations, came together with people representing vulnerable and affected communities such as sex workers, intravenous drug users, transsexuals, homosexuals, men who have sex with men, and people living with HIV/AIDS. Two years after Barcelona, they came together under the banner of "Access for All", this conference's theme. Picking up where Barcelona left off, the conference ran along five tracks--basic science, clinical research and treatment, epidemiology and prevention, social and economic issues, and policy and programme implementation.

Special emphasis was given to leadership, and communities most vulnerable to HIV. There was at least one person living with HIV/AIDS in almost every session, although an element of tokenism seemed apparent. The organisers, however, did attempt to redress this at the closing ceremony, where women and marginalised communities were featured prominently.

There were clearly two parallel conferences taking place, the one that took place in the plenaries and workshops in the main halls, and the other in the Global Village in the adjacent complex, reflecting al] too starkly the divide that exists between the reality of those living with and affected by HIV/AIDS and the cadre of donors, politicians, celebrities and scientists from Geneva, New York or Bangkok.

At Barcelona, HIV/AIDS was accepted as an infectious disease crisis, and the Global Fund to Fight AIDS, Tuberculosis and Malaria was launched. In Bangkok, calls were loud and clear, however, that HIV/AIDS must be seen as a human fights and development issue, and that the Global Fund needs to honour its own commitment to start funding more countries. Governments were also exhorted to increase their efficiency and effectiveness in disbursing these funds.

The debate over whether to promote abstinence over condom use was criticised numerous times as a waste of time and resources and a major distraction, taking attention away from more urgent matters. The need to use different strategies was widely and loudly acknowledged. Abstinence alone, it was agreed, just will not do the trick.

In spite of efforts to move away from the biomedical focus that tends to figure prominently in AIDS arenas, it was this, together with certain economic and financial aspects, that came to the fore most overtly. The first few days of the conference seemed to be all about increasing funding for treatment. It was only in the latter half that women, young people, and people living with HIV/AIDS received more attention at the plenary sessions.

The presence of many concerned government officials was very heartening. At the same time, governments were taken to task for the inefficiency of many of their institutions, especially in public health, not to mention lagging political will in spite of all the good words in their speeches.

Furthermore, the negative effects of structural co-factors--poverty, gender, donor policies and health sector reforms--were highlighted. The experience of the sexual and reproductive health and rights movement has been similar in regard to these issues, which are the hardest to address as they require a real social, political and economic transformation at the global, national and personal levels.

Issues that seem to persist unresolved from conference to conference included NGO and programme sustainability, the need to use dual protection, increased condom use, the need for strategic and committed leadership at all levels, and the need for additional resources--funding, human resources, facilities, training and infrastructure. These were all revisited.

The link between HIV[AIDS and sexual and reproductive health was prominently tabled. HIV/ AIDS is transmitted primarily through unsafe sexual behaviour. Additionally, people living with HIV/AIDS, especially women, will face many distinct sexual and reproductive health concerns--safe sex, contraception, abortion, STIs/RTIs, safe pregnancy and delivery, whether to breastfeed. A worrying sign in this conference, however, was that in most cases, reference to sexual and reproductive health was restricted to family planning, voluntary counselling and testing (VCT), and prevention of mother-to-child transmission of HIV (PMTCT). In a session on the MTCT+ initiative, there was even a suggestion to move towards a more family-oriented programme, risking the exclusion of all those women who fall outside traditional definitions of family norms and practices.

Many issues raised at the Cairo ICPD were repeated in Bangkok--cost of services, access to quality of care, integrated services, the benefits of partnerships and changing donor policies. The first three issues are addressed by the sexual and reproductive health field in relation to how health sector reforms limit women's access to services. The one group clearly clued in about the need for re-linking HIV with sexual and reproductive health and fights was young people. They were also the only ones who genuinely talked not only about reproductive rights and sexual rights but also health fights and human rights more broadly in this context.

The importance of learning lessons from sexual and reproductive health practitioners, as well as working towards meeting ICPD goals, instead of just the Millennium Development Goals (MDGs), could save us valuable time, time that we do not have to waste. Yes, addressing HIV/AIDS bas an urgency that sexual and reproductive health cannot as easily garner. Yet to treat the two along vertical lines that intersect at selected points is self-defeating--and for this it is not just donors or governments who are to be blamed. As practitioners, maybe NGOs too should take a look at what and who has influenced our decisions, and why even NGOs deal with HIV/AIDS and sexual and reproductive health and fights in separate compartments. In general, it was the people living with HIV/AIDS and young people at the conference who were not afraid to talk about the issues that remain "sensitive" today because of rightwing politics or religion.

As we celebrate ten years of ICPD, we must ask if there has been any real impact on people's lives at grassroots level, and what has been the impact on HIV/AIDS. If only 7% of the people that need treatment are receiving it, and if the biggest risk factors for HIV transmission are to be a young woman and married, then we desperately need to move forward through meaningful partnerships and collaboration between the so-called experts and those most vulnerable and affected. We need to put human rights at the centre and be frank about human sexuality, both male and female, and the politics of gender and economic disparities. Maybe then we will have something radically better to report in 2006.

Asian-Pacific Resource & Research Centre for Women (ARROW), Kuala Lumpur, Malaysia. E-mail: [e-mail]

Summaries of selected presentations and sessions

HIV/AIDS: a human rights crisis

The fact that only some 7% of the six million people who need ARV therapy have access to it should be viewed as a gross violation of the right to health. The human rights dimension can also be extended to all the 34 million people with HIV who have to live with the discrimination, stigma and exclusion they experience as a result of their condition. In an era when the need for scaling up HIV/AIDS interventions has been identified as critical, a rights-based framework becomes particularly useful for holding governments accountable to their commitments. Taking this position gives us a good perspective and an added advantage when looking at the various instruments and institutions that govern HIV/AIDS interventions, be it WHO's 3 x 5 initiative or the MDGs. The whole issue of treatment should be addressed as a right-to-life issue--access to affordable treatment is essential to prolong the lives of those with the virus. It also becomes very important that all people living with HIV/AIDS, including young people, are made aware of their rights. Government officials, on the other hand, need to recognise that human rights and not just the WTO or TRIPS must be used as tools when planning and implementing HIV/AIDS policies and programmes. (1)

The role of governments is critical, as they have the obligation to ensure equal access of all citizens to quality public health services. Unfortunately in some countries, people living with HIV/AIDS are subject to state-based discrimination because of their status. In particular women, young people, drug users, migrants and other marginalised communities living with HIV/AIDS are more exposed to direct abuse and discrimination because of gender, social, political and economic inequalities and inequities. In societies throughout the world, death and disability, including in association with HIV/AIDS, are not distributed equally. Governments bear the primary responsibility for fighting the epidemic and for setting up the necessary institutional machinery to implement this responsibility. Concrete steps need to be taken, through legal, policy and health sector reforms to ensure equal access to all, and nondiscrimination in service and treatment provision. To achieve these, open engagement with those most affected/vulnerable, and the creation of a supportive environment for people living with HIV/AIDS is a prerequisite. HIV/AIDS is a rapidly evolving epidemic, it is not enough to fight it through information and education alone; the fight to stop AIDS is a fight to recognise the rights of the most marginalised people in the world. (2)

(1.) Robinson M. Placing human rights at the centre of responses to HIV/AIDS. Beyond Cancun: whose access counts? Satellite session. AIDS 2004. Bangkok. July.

(2.) Khan Z. Human impact of HIV/AIDS policies. Overcoming challenges through empowerment and action. Plenary P105. AIDS 2004. Bangkok. July.

Condoms are the best protection

In an age of technology and science, it is a tragedy that people are still ignorant of their own bodies and ways to protect themselves from HIV. In order for prevention to work, policymakers need to stop arguing about the merits of abstinence over condoms. Condoms are the best and most reliable means available to protect against HIV transmission. (1)

(1.) Obaid T. Ensuring access to women and youth. Plenary P103. AIDS 2004. Bangkok. July.

Critical review of new funding mechanisms

The HIV/AIDS epidemic is a development issue, and this applies most of all to funding. Although contributions to the global fight against AIDS have grown from $0.3 billion in 1996 to $4.7 billion in 2004, there is an alarming shortfall. Funds are currently available through various channels, from bilateral and multilateral sources to governments, NGOs and the World Bank, in addition to specially established funds such as the Global Fund, UNAIDS and contributions by private corporations and foundations. Unfortunately, each source operates with different objectives, targets, requirements and even ideologies, making for a very fragmented funding landscape, one that is inadequate for addressing the magnitude of the HIV/AIDS situation today.

Three major challenges need to be overcome if this situation is to be improved. First, there needs to be a significant increase in funds, up to four times present amounts. New funding instruments need to be developed, including cancelling the debts of developing countries. Funding must also be in addition to that committed for implementing the MDGs. Secondly, donor cooperation and harmonisation must be increased through greater transparency on donor contributions, coordination of funding with country national plans and involvement of civil society in programme design and implementation. Thirdly, comprehensive programmes must be designed with priorities that are based on needs, not ideology. Controversial aspects must be addressed so that treatment is not seen (or funded) in isolation of prevention, care and support, so that vulnerable groups such as sex workers, intravenous drug users, migrants and refugees are not neglected. (1)

(1.) HRH Princess Mabel van Oranje, Open Society Institute, Netherlands. Access to resources: commitment and accountability. Plenary PL01. AIDS 2004. Bangkok. July.

Generic antiretroviral drugs essential

Lack of access to antiretroviral (ARVs) therapies could soon emerge as the greatest humanitarian crisis of the developing world. The World Trade Organization (WTO), dominated by wealthy states and the interests of corporate capital, is generally viewed as a major stumbling block. However, those in developing countries cannot wish the WTO away, but must find ways to use it to their advantage. One challenge is to provide access to quality, yet affordable, products. This means generic drugs unencumbered by patents.

In Bangkok, Thai Prime Minister Shinawatra made a commitment to increase production of generic drugs. Thailand now relies on its national budget for the production of generics, and soon ARVs will be included as part of the permanent health insurance package. Currently, 40,000 people are registered for the ARV programme in Thailand, within WTO guidelines. However, the United States has since succeeded in pressuring for patent extensions and data exclusivity, which may block other countries following in Thailand's footsteps. (1)

Patents on processes, technologies and products greatly limit ARV access. However, within the WTO Doha Declaration, August 2001, Paragraph 6 recognises the flexibility of the TRIPS agreement and the right of countries who are too poor to manufacture their own drugs to import generics from other countries. Thus, developing countries can and must take steps to use the flexibility allowed in TRIPS. Governments must study TRIPS and the Doha Declaration and then choose options that will maximise existing laws and policies to ensure access to ARVs. Also needed is improved coordination between different government agencies. In general, countries can choose between finding ways to import generic ARVs or manufacture their own. (2)

(1.) Wibupolprasert S. Beyond Cancun: whose access counts? Satellite session. AIDS 2004. Bangkok. July.

(2.) Khor M. Beyond Cancun: whose access counts? Satellite session. AIDS 2004. Bangkok. July.

Social transformation needed to reduce vulnerability to HIV/AIDS

While it has been acknowledged that gender plays a key role in increasing an individual's vulnerability to HIV transmission, tackling gender and the related sexual and structural inequalities and inequities between men and women are not normally discussed. The HIV prevention discourse has always preferred to focus more on short-term strategies, such as giving out condoms or calling for more research. While such strategies are very important, they are more technical than structural, and will not make a dent in gender disparities. Over the years, the definition of "gender" itself, whether in its application in gender-mainstreaming programmes, or in NGO initiatives on male involvement in sexual and reproductive health programmes, has been narrowed, watered down and de-politicised. There is a need to revisit the feminist consciousness of the 1970s, which believed that the personal is political, and in building solidarity and collective action. The political nature of gender oppression requires a political response.

(1.) Tallis V. Beyond gender mainstreaming: experiences from South Africa. Integrating gender and sexuality in prevention, care and treatment programmes. Symposium Sy20. AIDS 2004. Bangkok. July.

Youth access to prevention, treatment, care and information: still out of reach

Young people--both the important role they can play and the importance of reaching out to them--are commonly spoken about since ICPD. The reality, however, is that young people, who are generally treated as targets for prevention, still feel marginalised, and mainstream institutions have yet to involve them in a meaningful way. This fact was reiterated by Raoul Fransen of the Young Positives, when he pointed out that although young people aged 15-24 account for 50% of new HIV infections, and 35% of people with HIV and AIDS fall in this age group worldwide, in Barcelona, only 200 of the 15,000 delegates were below the age of 30.

In fact, none of what he said was new--that young people are not a homogeneous group; that young people have their own distinct needs; that young people are the most affected by HIV/AIDS; that they are a resource and want to be actively involved; that they are part of the solution, not the problem; and that youth need properly resourced, youth-friendly services. Most programmes aimed at young people are outdated, leading to "AIDS fatigue" with the same old messages, especially "ABC", which neither recognises sexual and reproductive health and rights nor provides young people with realistic options. Fransen spoke against tokenism and stressed the need for real participation in policymaking, planning, implementation and evaluation.

Fransen's recommendations were to include youth in National AIDS Committees and other bodies and in preparing high-level declarations. Positive prevention strategies are essential as they also address the sexual and reproductive rights and needs of positive young people, including access to commodities and services, options for safe sex or for having children, and exploring sexuality.

Leadership at the global level is critical for reducing North-South disparities, upholding commitments made and increasing resources for young people. Equally important, however, is leadership in ensuring young people have access to their sexual and reproductive rights, supporting young people to exercise their rights through appropriate legal frameworks, and increasing youth participation through effectively structuring their involvement. However, just as the state has responsibilities, civil society and young people must also take responsibility for holding the state accountable.

(1.) Fransen R. Young Positives. Plenary PL03. AIDS 2004. Bangkok. July.

Beyond the syndromic: how STI treatment contributes to the control of HIV

Sexually transmitted infections (STIs) are on the increase worldwide, and calls for screening and treating STIs to reduce HIV transmission rates are still being made. Monitoring and evaluating the effectiveness of this strategy, even in selected interventions rather than as a universal strategy, have raised new matters to consider.

Even though WHO estimates there are 340 million cases of curable STIs worldwide, namely chlamydia, gonorrhoea and syphilis, significant barriers to screening exist, related primarily to the lack of simple, rapid screening tests. In most resource-poor settings, or when working with vulnerable groups who are not likely to return for test results, the best options have been either syndromic management or rapid tests such as immunoassays, agglutination and immuno-chromatography. However, most STI tests are expensive, cannot provide accurate results and are not appropriate or user-friendly in many primary health care settings.

Some scientists have begun to apply the ASSURED measure to determine whether new, rapid-testing technologies are affordable, sensitive, specific, user-friendly, rapid, robust, equipment-free and do-able. So far, research from Haiti has shown that ASSURED rapid tests have dramatically reduced congenital syphilis rates over a three-year period, and are relatively cost-effective as well. Rapid-test studies in Benin and South Africa are examining the impact of chlamydia and gonorrhoea screening on reducing HIV/AIDS transmission. Another major benefit of rapid tests for the future is that they need not be restricted to clinic-based settings, and can be included in prevention of mother-to-child transmission, maternal and child health, and voluntary counselling and testing packages. (1)

The case for linking HIV/AIDS reduction with STI reduction is supported by evidence from sub-Saharan Africa. WHO estimates that of the 70% of women in the region who receive antenatal care, only 38% were screened for syphilis. 49-67% of pregnant women with active syphilis had adverse pregnancy outcomes, including miscarriage and stillbirth. Studies reporting a decrease in STI rates found this has been linked to lower HIV transmission rates. Challenges to screening and treating syphilis, however, include poor infrastructure and transportation facilities, and the need for quality of care. Additionally, screening and testing facilities and condom use must be increased if STI rates are to come down. (2)

Another possible strategy is targeted STI screening programmes aimed at vulnerable groups. Studies among sex workers in Cote d'Ivoire have looked at three ways of treating STIs--diagnosis and treatment of symptomatic sex workers; systematic screening and treatment, including of asymptomatic sex workers; and presumptive treatment for those who attend primary health centres. While STI algorithms for sex workers showed a decline in HIV transmission, these algorithms were acknowledged as sub-optimal tools.

The only other alternative at present is to do nothing. Presumptive treatment is a potential alternative strategy, especially in high prevalence settings, where it is recommended at the initial visit due to inadequacies in ensuring follow-up visits. In all cases, other STI control strategies must be reinforced. The overall recommendation is to incorporate STI screening and treatment for sex workers into a comprehensive package that is accessible through the primary health system and developed with community participation. Commitment, resources and involvement of the "right" people are essential. (3)

(1.) Peeling RW. Point of care tests for STIs: new opportunities for the control of HIV and other STIs. Symposium Sy06. AIDS 2004. Bangkok. July.

(2.) Kawonga D. Bring back syphilis testing. Symposium Sy06. AIDS 2004. Bangkok. July.

(3.) Laga M. Why wait for symptoms: role of systematic screening in controlling STIs among sex workers. Symposium Sy06. AIDS 2004. Bangkok. July.

Research on antiretroviral pill for HIV prevention

While most speakers at the conference predominantly spoke about the importance of condom use in preventing HIV transmission, condoms alone cannot suffice in the fight against the epidemic. One possible new alternative is prophylaxis using ARVs, in particular tenofovir, in preventing HIV infections, especially among highly vulnerable groups. Tenofovir has provided 100% protection in preventing HIV transmission in macaque monkeys. It is FDA-approved, and has minimal toxicity and drug resistance. A placebo-controlled, double-blind trial in Cambodia involving dally oral use of 30g of tenofovir to 950 women engaged in transactional sex has demonstrated potential benefits. If found effective, tenofovir will give women a personal, private, self-controlled prevention method, and if infection does occur, administration of tenofovir may enhance anti-viral immunity. All women participating will get access to extensive counselling, condoms and STI treatment. Women who test positive will be referred to clinics. If this trial proves efficacious, a two-year open study will follow. (1)

(1.) Page-Shafer K. Use of ARVs in prevention of HIV infection in high risk populations. AIDS 2004. Bangkok. July.

HIV prevention through microfinance, gender and HIV training and community mobilisation

Taking a more structural approach to prevention, which generally focuses on behaviour change and education, the IMAGE project in South Africa is attempting to look at poverty, cultural norms and the laws and policies that affect behaviour change. The IMAGE project was initiated in eight South African villages, covering a population of 60,000 and includes a range of components from microfinance and gender and HIV training, to community mobilisation and evaluation. In response to the initiative, women are reported to be trying out new behaviours, and there is greater engagement with women and young people, while community-level responses have been recorded. Challenges however, include trying to sensitise donors to the importance of funding such initiatives, building new inter-sectoral partnerships, and being prepared for unpredictable community responses that may pit basic needs against HIV/AIDS project goals. Lessons learned from the IMAGE project are that structural changes require time and support, that the term "empowerment" may need to be redefined, that change is a challenging process, and that microfinance is only a means to an end. Finally, the policies and attitudes of donors and financial institutions in developed countries are instrumental in ensuring that structural change can take place and that poverty is alleviated. (1)

(1.) Kim J. Addressing underlying social issues putting women at risk. AIDS 2004. Bangkok. July.

Coordination between maternal and child health, family planning and prevention of perinatal HIV transmission

Although there are synergistic benefits in linking reproductive health with PMTCT programmes, in particular to capitalise on the fact that most women first encounter the health system to meet a reproductive health need, this linkage is not made in reality. Improving reproductive health services will attract more women and from there, providers can step up and/or integrate HIV/AIDS prevention, treatment and care. However, one of the key drawbacks is the weakness of existing health systems. Among key actions needed to improve this situation is to increase coordination of policy and programme planning and management, resource mobilisation and supply, service delivery and monitoring and evaluation.

Currently the most common scenarios encountered are PMTCT programmes located either in the MCH or reproductive health division under the Ministry of Health; or located within National AIDS Control Programmes. The former has ready infrastructure and human resources, while the latter opens up access to more financial resources.

As a means of improving the coordination between the two areas, potential strategies could be to form multi-sectoral coordination bodies; introduce an integrated plan for scaling up HIV-related reproductive health programmes; and to harmonise donor interest and government awareness. (1)

(1.) Ngongo. Meet the Leaders LM14. AIDS 2004. Bangkok. July.

Condoms and the fight against HIV/AIDS

There is no single answer or solution to preventing HIV. A lesson from 40 years of family planning can be applied here: the more options available, the more choices people have to protect themselves. (1,2) Thus, promoting condom use must not be abandoned or neglected.

Evidence at the individual level from various cohort studies of seroconversion rates among discordant couples reveals that condoms are 85-90% effective in preventing HIV transmission. The reality is also that rates of consistent condom use are not high, and are lower within primary partnerships. Therefore, there is a need to learn how to integrate condom use into a multi-faceted prevention programme that leads to behaviour change. (1)

Most condom interventions are about male condoms only, although the female condom has been around for 11 years. Most often, the case against the female condom is that it is hard to use. However, people have been taught how to use it. A challenge is to make the female condom available and accessible. (2)

Lessons from Ghana, where the national slogan is "If ifs not In, ifs not On", show that a systematic strategy and high profile advocacy can ensure wider distribution of female condoms. A systematic strategy includes targeting the general population, and not just sex workers or other groups perceived as high risk. The building blocks for any effective strategy include valid data, empowerment through training, documentation and dissemination of information about effective pilot projects and subsequent scaling-up, partnerships with civil society, and monitoring and evaluation. Another lesson from family planning applies here as well--involving men leads to higher rates of acceptance and use. (3)

(1.) Hearst N. Condom promotion for AIDS prevention in the developing world: is it working? HIV prevention: promoting dual protection in family planning services. Satellite. AIDS 2004. Bangkok. July.

(2.) Warren M. AB and C of the female condom. HIV prevention: promoting dual protection in family planning services. Satellite. AIDS 2004. Bangkok. July.

(3.) Lamptey AS. Experiences from Ghana. HIV prevention: promoting dual protection in family planning services. Satellite. AIDS 2004. Bangkok. July.

Microbicides research

At present, there are four classes of potential microbicides, and more in the pipeline. The majority of microbicides are in pre-clinical and safety studies, while several have begun efficacy testing, and the results will be critical. A miracle cure is not expected, but it is important to ensure access as soon as possible, through rapid approval, licensing, import, export, distribution and marketing of any product that passes critical tests. To date, the development of microbicides has been supported almost entirely by governments and foundations, with virtually no private sector investment. (1)

Protocol studies on the safety and tolerability of vaginal tenofovir gel show that it warrants further investigation, as it is well-tolerated and most adverse reactions are mild. (2) Phase I of a six-month trial in Thailand on the safety and acceptability of Carraguard, a microbicide derived from a seaweed, found it to be sale and acceptable among the women participants of the 55 heterosexual couples who used it an average of two to three rimes a week together with condoms. In the next phase of the study, more data are needed on safety in men. (3)

Female-controlled methods are dependent on male cooperation. Quantitative studies from Botswana over a two-year period have found that men are often willing to support women's participation in microbicide studies, although they are concerned about the safety of their partners as well as themselves, and have shown interest in learning more about their partners' participation in these studies. (4)

(1.) Rosenberg Z. Expanding options and access for prevention. Plenary P104. AIDS 2004. Bangkok. July.

(2.) Meyer K. Safety and compatibility of vaginal tenofovir gel. Female-initiated prevention technologies. Oral abstracts C11. AIDS 2004. Bangkok. July.

(3.) Kilmarx P. Safety and acceptability of Carraguard among heterosexual couples. Female-initiated prevention technologies. Oral abstract C11. AIDS 2004. Bangkok. July.

(4.) Smith D. Men's perspectives about microbicide trials. Female-initiated prevention technologies. Oral abstracts C11. AIDS 2004. Bangkok. July.

Making participation real and effective

Participation of people living with HIV/AIDS in policy formulation, programme design and implementation, and monitoring and evaluation has long been promoted as a key strategy in HIV/ AIDS work. However, the extent that participation really happens and its impact are rarely reported. A study by Panos International in Haiti, Nepal and Zambia found that participation does not always ensure influence on the outcome of policymaking. Instead, an element of tokenism characterises attempts at participation in all three countries. People living with HIV/AIDS are insufficiently engaged in the roll-out of treatment programmes, and there is a lack of information and information-sharing. People living with HIV/AIDS also felt that an almost singular emphasis on condoms and treatment at specific project sites has led to the neglect of other concerns such as domestic violence, childcare, immunisation and reproductive health. Recommendations emerging from this study are that for participation to be genuine and effective, several things need to be in place--a safe space for people living with HIV/ AIDS, accurate and up-to-date information, and a clearly defined process for participation in policymaking, including guidelines and capacity-building. (1)

(1.) Whose voice is heard: agenda setting in the response to the epidemic. Panos session. AIDS 2004. Bangkok. July.

Financial sustainability of NGOs

That the issue of NGO sustainability should arise is almost a given in any NG0 context, but exactly what is meant by it is rarely discussed. Is it about ensuring funds for the core functions of an NGO? How long should an NGO exist? Do projects end with the project cycle or when their objectives are met? If communities take over, how does the transfer of responsibility occur? If the private sector takes over, how will conflict of interest be addressed and will controversial issues be abandoned? If service fees are introduced, how will the poorest and most vulnerable access services, and how will long-term activities like advocacy and gender sensitisation be supported?

The demand for NGO self-sufficiency imposed by donors, as well as their interest in efficient short-term project outputs, does not take into account these complex issues, nor recognise structural constraints on NGOs.

Sustainability should be viewed by NGOs as a means to ensure continuity and consistency in solving a problem, and as a means for reducing dependency on donors and thus acceptance of donor conditionalities. Some recommendations for achieving sustainability in this context are to increase donor transparency through independent monitoring by NGOs, diversification of funding sources, investing in institutional capacity-building, including leadership transition, institutional and staff development, identification of technical assistance needs by NGOs themselves, and promoting local ownership through the identification of problems and solutions and taking the lead in decision-making processes. (1)

Additionally, there needs to be greater investment in capacity-building for basic project management which can be a catalyst for sustaining critical programmes. Employees of NG0s should be treated with respect and well-compensated to avoid high staff turnover and low morale. Unfortunately, these are not priority considerations for donors who, because they focus on short-term outputs, fail to see the link between investing in organisational management and staff motivation and sustaining longer-term efforts to realise a vision. (2)

(1.) Sciortino R. Symposium Sy02. AIDS 2004. Bangkok. July.

(2.) Dillon F. Symposium Sy02. Bangkok. July.