Government or Donor: The Budget for HIV/AIDS Control and Financial Commitment in Bandung City, Indonesia

The number of HIV/AIDS cases in Indonesia has steadily increased since 1987. West Java Province, especially Bandung City, had the highest HIV/AIDS cases among other districts/cities in 2016. Some stakeholders' interventions overlap with others, leading to inefficient use of the limited government budget and flattening international donor funding. This study aimed to estimate the HIV/AIDS budget in Bandung City and then segregate the share of the budget by funding source and objectives. This study was a part of the Priority Setting Involving Stakeholder Using Multiple Criteria (PRISMA) project in 2017 to prioritize HIV/AIDS interventions knowing that Bandung City had the highest HIV/AIDS cases. Data from several institutions and relevant budget allocations were obtained before (2016) and after (2018-2019) the PRISMA project. HIV/AIDS control programs in Bandung City largely depend on international funding: 49% in 2016 (~USD208,898), 85% in 2018 (~USD386,132), and 71% in 2019 (~USD389,943) for a total of ~USD1,433,216. The largest budget was allocated to core interventions, with prevention dominating the budget since 2018. The budget allocated for prevention increased significantly from 2016-2019, most likely under the influence of the PRISMA project.


Introduction
The number of HIV/AIDS cases in Indonesia has steadily increased since 1987. 1 West Java, the country's most populous province, 2 is ranked third highest among 34 provinces in Indonesia regarding the number of diagnosed accumulated HIV/AIDS cases. 3 Bandung, the capital city of West Java, has the province's highest number of HIV/AIDS cases, with 3,116 cumulative cases reported in 2019. 4 With a large and dense population (>2.5 million people), Bandung City is at risk of experiencing an ever-increasing number of HIV/AIDS cases.
Different stakeholders carry out various interventions to control HIV/AIDS in Bandung City. By the time this study was conducted, multiple Bandung City government agencies had implemented HIV/AIDS programs for particular purposes: providing medicines, diagnostics, prevention programs, and economic mitigation. Non-governmental organizations (NGOs) actively reach out to marginalized key populations (e.g., sex workers, transgender people), addressing stigmatization and advocating. 5,6 Universities have conducted operational studies, such as experimental treatments or models for school health promotion programs. 7,8 Some of these interventions overlap with others, leading to inefficient use of the limited government budget and flattening international donor funding.
The National AIDS Spending Assessment (NASA) report shows and analyses HIV/AIDS programs and intervention expenditures carried out by public and international partners. However, the report does not provide data at the city level and only estimates budgets at the provincial level. 9 Differing contexts among settings have prompted tailored HIV/AIDS programming suited to each city and district because the Indonesian Ministry of Health supports the distribution of HIV/AIDS drugs in the country, and decentralized cities and districts focus on social and behavioral interventions. Moreover, key populations can benefit from non-HIV/AIDS programs not included in NASA reports, such as poverty reduction programs. Some spending for HIV/AIDS-related comorbidities among key populations is melded into seemingly non-HIV/AIDS-related health programs, making expense tracking a challenge. 9 Financial support is an important element in HIV/AIDS prevention intervention, 10,11 and proper budget tracking to estimate actual amounts allocated by the government is needed to monitor its political commitment to HIV/AIDS issues and assess its sustainability. 12 The Priority Setting Involving Stakeholder Using Multiple Criteria (PRISMA) project was established in 2017 to support the priority setting of HIV/AIDS prevention activities in Bandung City for greater efficiency and organization. An investment case analysis was conducted as part of the situational and response analysis for this project. 13 Such information is necessary to evaluate the current budget allocation and may serve as crucial input for policy revision. This study had two purposes: first, the study estimated the total HIV/AIDS budget based on the nature of the interventions/program and funding source; and second, the study analyzed the interventions and budget data in 2016, 2018, and 2019, and observe the changes in prioritization. This study was unique as the approach could identify the budget allocated for HIV/AIDS, even if the programs or interventions did not explicitly state that they aimed for the disease. As such, this study could comprehensively picture the budget allocated for HIV/AIDS.

Method
The PRISMA project implemented a joint planning and priority-setting exercise for Bandung City HIV/AIDS stakeholders. The project used evidence-informed deliberative processes, which combined the multi-criteria decision analysis (MCDA) and accountability for reasonableness framework. 13 Combining the two emphasized a fair and rational process, allowing for more consensus in decision-making. The MCDA has proven useful in ranking interventions based on performance criteria. 14 In terms of controlling HIV/AIDS, this approach can increase collaboration among stakeholders in responding to the epidemic to identify the budget spent on interventions related to HIV/AIDS and observe the changes in spending and prioritization. Therefore, this study developed a method called Budget Tracking, which was generally defined as recording and analyzing the revenue and spending of institutions over a given period to increase the transparency of fiscal data. [15][16][17] Budget tracking is a refined investment case study that classifies the type of budget, funding sources, beneficiaries, and expected outcomes through budget analyses and in-depth interviews with program implementers. The aim was to consider HIV/AIDS interventions not explicitly specified in HIV/AIDS implementation reports, such as the NASA report focusing on targeted people living with HIV/AIDS (PLWHA) and HIV-impacted communities. 13 To trace all interventions and budgets related to HIV/AIDS, this study began by identifying institutions and organizations that were tasked with or potentially have contributed to HIV/AIDS control based on available reports and suggestions from the Bandung City AIDS Commission, Health Office, and Regional Secre tariat in Social Welfare Sector in 2016. A total of 11 govern ment agencies and seven NGOs in Bandung City were included in this study, of which the activities and budgets were analyzed between July 2016 and December 2019. Staff members and program managers in relevant government agencies and NGOs were interviewed about their HIV/AIDS-related activities. Inter ven tions and/or programs were grouped into several funding classifications, such as funding source and allocation and intervention design and outcomes ( Table 1).
The data processing and analysis were divided into several steps. First, stakeholders or institutions related to HIV/AIDS interventions were identified through discussions with the Bandung City AIDS Commission. Second, the budget percentages allocated for HIV/AIDS-related interventions were calculated based on the total allocation of funds devoted to activities related to HIV/AIDS. Fund allocation was based on the unit cost of each activity and resources used, which were obtained based on the number of beneficiaries, working hours, and percentage of use. This approach was similar to that applied in the micro-costing analysis. 18 Third, several groups of interventions were identified based on their program outcomes: health promotion, prevention, diagnostic, treatment, and impact mitigation. 19 Fourth, the group of interventions was further differentiated into several categories to observe the type of the interventions being implemented: a) the source of funding, categorized as donor or government; b) specific or integrated interventions, "specific" if it was aimed only at an HIV/AIDS program and as "integrated" if the delivery of the HIV/AIDS program was integrated with programs/services for other diseases; and c) core and support interventions, 20-23 core interventions were the main activities directly targeted at the beneficiaries, while support interventions were supplemental to core activities such as meetings and training. Last, the data were observed and analyzed concerning the changes in the allocated budget within the context of budget spending and prioritization.
This study complied with all administrative requirements for government agencies' financial reports. The surveys were conducted before (2016) and after (2018-2019) the PRISMA project to observe the changes in priority setting among the government agencies and NGOs (data collection was not conducted in 2017 to allow stakeholders to implement the results of PRISMA project implementation for prioritizing the interventions in 2018 and 2019). All budgets were calculated in Indonesian Rupiah (IDR) and converted to United States Dollars (USD) using the 2016 Bank of Indonesia exchange rate of IDR14,237/USD. All authors reviewed all the interview results, and disagreements were resolved through discussion. However, this rarely occurred as the results were quite straightforward and in line with the function of each institution. To minimize possible bias, the Bandung City AIDS Commission determined the proper institutions to be interviewed. It was later confirmed by Bandung City Health Office and Regional Secretariat in Social Welfare Sector.

Results
HIV/AIDS stakeholders implemented HIV/AIDS interventions based on their organization's tasks and capacities. Tables 2 and 3 show the interviewed government agencies and NGOs, as well as their task description, examples of interventions, and year of implementation to ensure that such institutions are relevant to be interviewed. The figures show the result of the interview in the form of Budget Tracking results.
Several agencies, such as the Health Office, Social Office, Population Control and Family Planning Office, and Bandung City AIDS Commission, were given specific tasks in HIV interventions. The examination revealed HIV programs at every agency implemented from previously unidentified non-health-related sectors, although inconsistently. For instance, in 2019, the Communication and Information Technology Office allocated a budget to promote HIV/AIDS prevention through public radio. The Population Control and Family Planning Office was no longer intervening because of the transfer of management of HIV/AIDS control within the households to the Bandung City AIDS Commission. In contrast, the National Unity and Politics Agency no longer delivered interventions on HIV/AIDS because its focus shifted to early drug use prevention among adolescents.
Interventions implemented by NGOs were more consistent over the years, and they were designated unequivocally to indicate their HIV/AIDS program activities and targets. Most NGOs whose representatives were interviewed were implementors of, or even initiated by, the Global Fund programs, except for the last NGO because it focused on overcoming cases of sexual violence against children that were not specific to HIV/AIDS. International funding allows NGOs to undertake activities to benefit key populations and PLWHA.
However, these NGOs and their activities were highly susceptible to the volatility of international funding, to change policies at the national and provincial levels, and to policy recommendations from regional stakeholders. Shifts in activity implementation also occurred within NGOs. Of the seven surveyed NGOs, only five consistently delivered HIV/AIDS control activities in 2016, 2018, and 2019. One NGO stopped implementing HIV control activities as it shifted its focus to tuberculosis control. Another NGO started implementing HIV-related activities in 2018 and 2019 based on a recommendation from the Bandung City AIDS Commission. Decentralization has allowed regional governments to provide more fiscal space to allocate a budget for epidemics representing a national emergency, such as HIV/AIDS. In addition, international donors and Bandung City Government's actual budget for HIV allo- The funding for HIV programs in Bandung City was dominated by government agencies (2016) and donors (2018-2019). The donor funds were channeled mostly through NGOs, although donors also contributed to programs implemented by government agencies, such as the Health Office and the Bandung City AIDS Commission. In total, investments in prevention activities increased from 2016 to 2018, with the government taking over the funding in 2019 for several prevention activities that were previously donor-funded. In addition to prevention, treatment, and health promotion programs, PLWHA received increased funding from donors and the government in 2019.
The government agencies' budget dropped from USD221,698 in 2016 to USD70,531 in 2018 before increasing to USD156,015 in 2019. Changes in the government budget were attributed to a major shift in the tasks and responsibilities of government offices, as mandated by the mayor: donors funded all NGOs but some government agencies, such as the Health and Education Offices. The government's HIV budget dropped in 2018 because of a major policy shift regarding the tasks and responsibilities of the government agencies, as mandated by the mayor, although the budget increased in 2019.
In terms of integration between HIV/AIDS and other Providing guidance and assisting registration for regional IEC of drugs and HIV/AIDS prevention for students 2016 Politics Agency NGOs and ensuring alignment of city-level community and the general public. activities with national and regional values. Municipal Police Assisting the regional head in enforcing regional regu-IEC for the prevention of prostitution and drug and 2016, 2018, lations and maintaining public order. alcohol misuse. and 2019 Manpower Office Developing and implementing policies on human re-Anti-stigma and discrimination policy advocacy in 2016, 2018, sources empowerment and protection, industrial relation, workplaces. and 2019 and capacity building.

Regional secretariat in Social
Coordinating and facilitating programs across government IEC on HIV/AIDS for the general population, including 2016, 2018, Welfare Sector agencies in the areas of religious affairs, education, youth vulnerable families. Act the regional government repre-and 2019 empowerment, and social welfare. programs, most HIV/AIDS programs were categorized as "specific," e.g., funding was channeled specifically for programs delivering HIV/AIDS content/services without any integration into other programs (Figure 1). Although government funding in 2016 was more evenly split between HIV/AIDS-specific and integrated programs, the funding was channeled more toward HIV-specific programs in the following years. A similar trend favoring HIV/AIDS-specific programs was also observed in the donor-funded programs, particularly in 2019 ( Figure 2). Figure 3 shows budget segregation based on core and support interventions. The core intervention budget shared more than 75% of the total budget during the 3year observation period, indicating that more was allocated for interventions that directly target beneficiaries.
Of this allocation, NGOs were able to engage in a steady budget for core interventions. In contrast, the government reallocated budget from core interventions in 2016 to support activities, such as coordination meetings and training, including those conducted by the Bandung City AIDS Commission in 2018 and 2019.
The prevention and treatment budgets increased after 2016. The increase in the prevention budget was mostly related to increased human resource spending for outreach to injectable drug users. In 2019, the budget for health promotion was increased from USD29,829 in 2018 to USD52,082 in 2019 because of bigger attention from the Education Office to providing HIV/AIDS education at the junior high school level. In addition, diagnostics and mitigation were slightly reduced because the

Discussion
The results of this study highlighted the changes in HIV/AIDS control budget share in 2016, 2018, and 2019 at the government agencies' level. It was observed that the budget allocated for prevention significantly increased after the PRISMA project in 2017, which may suggest a priority change after the project implementation. Other findings indicated that donor funding consistently dominated the HIV/AIDS interventions budget, with prevention and treatment interventions having the highest share in 2018 and 2019 and budgets mostly spent on core interventions. Several inferences stand out based on these observations. First, international donors consistently dominate the HIV/AIDS budget in Bandung City. This pattern also applies at the national level and to most low-and middleincome countries. 24 To taper off from international fund-ing dependency, the government should start investing in interventions targeting key populations, such as IDUs, transgender people, and sex workers. Indeed, sustainable domestic funding is required to attain a robust response to the HIV/AIDS epidemic. 12 According to Piot, et al., ideally, such a transition "should include the following elements: duration of about five years; key financing or high-level political signees; clear and measurable financial targets (for donors and governments); economic and epidemiological data; costed HIV/AIDS strategies and trusting dialogue; reliable monitoring and evaluating systems; and binding incentives (penalties and rewards)." 25 These factors are important because donor withdrawal may influence the retention of those on treatment without proper planning and financing by the regional government.
Increased opportunity costs also are possible as financ ing is redirected from other crucial sectors to control the HIV/AIDS epidemic to compensate for the withdrawal. 26 In this context, the transition to relying more on the regional budget can be made by the government's implementation of the interventions or channeling funds through NGOs. Budget tracking provides an overview of allocations to anticipate funding overlaps and conflicts of interest. However, accessing government institutional budgets is difficult because of rigid protocols following the regulations. Public sector funding is limited, and competition occurs among diverse sectors. 27 This study found a similar situation in Bandung City, mostly because the government agencies aimed not only at HIV/AIDS reduction, but also at implementing various other programs. Reallocating government funding to HIV/AIDS control programs/interventions implemented by either government or NGOs would require a specific process. In this case, putting the time frame suggested by Piot, et al., into an overall transition plan is important. 25 Alternatively, increasing the HIV/AIDS control budget can be achieved by developing innovative and sustainable funding mechanisms. 28 Indeed, based on one of our focus group discussions (FGDs), rearranging the budget allocation among posts is more feasible for developing an effective HIV/AIDS control budget while not necessarily increasing the budget itself.
In terms of the NGOs' role, although they are important in outreach, counseling, and support for PLWHA, most NGOs in this study were funded by foreign donors who supported programs within a period. Thus, the sustainability of the interventions is at stake. 29 There is a legal limitation for NGOs to receive government funding regularly, and even the sum will not be comparable to the donor funding. Also, the administration for regional funding is potentially daunting for key populations. 30,31 Second, funding for most HIV/AIDS programs, both by the donors and the government, was still fragmented. The funding was mostly aimed at financing a single HIV/AIDS service/program instead of supporting integration with other relevant services. This pattern contrasts with major global guidelines that advocate integrating HIV/AIDS responses into broader health programs and services. 32 Among the suggested programs and services are those for tuberculosis, sexual reproductive health, 33 and even non-communicable diseases, such as cardiovascular disease, diabetes, and hypertension. 34 Such integration will enhance the impact and efficiency of the HIV/AIDS responses and strengthen person-centered care by addressing the broad health needs of PLWHA. 32,33 Integration of HIV and other services, such as immunization, 35 is also expected to reduce stigma and improve patient access to services.
Third, the share of the budget spent on core interventions consistently dominated over the years. After implementing the PRISMA project to prioritize interventions, the budgeting patterns of government institutions and NGOs showed some change, with the prevention budget significantly increasing in 2018 and remaining high in 2019. Although it cannot be claimed that this change is solely because of PRISMA, the project has likely had some role. The interviews result during data collection confirmed this finding, in which most government office and NGO representatives stated that the prioritization process of the PRISMA project influenced to some degree the decision to prioritize prevention and outreach. This development is important in the face of the prevention crisis as a result of interventions not being provided adequately and intensively enough and possibly not reaching the necessary individuals. 36 Such neglect may result in a rebound of the epidemic and catastrophic consequences, especially in the key populations. 35 However, implementing, monitoring, and evaluating HIV prevention interventions properly requires systematic data collection and analysis, and clear target outcomes. 35,36 Indeed, prevention interventions can have a maximum impact only if they are prioritized and made available without stigma and discrimination to those in need. 37 A prevention cascade adapted to the national/regional context would help design clear prevention interventions and measure their performance. 38 This study per formed an approach that relies heavily on interviews to provide a detailed budget composition, which was resource-heavy and time-consuming. This study successfully discovered activities that contribute to HIV control previous ly uncovered with other methods, such as NASA. It relies on accounting work, which tends to involve the regional budget office skimming for HIV/AIDS-related words in the budget reports.
This HIV/AIDS investment case analysis has limitations stemming from the inquiry's nature. First, this study did not anticipate the high turnover of program managers, especially in government agencies. In some agencies, data is only obtained from budget planning documents or estimations instead of the actual budget realization. Second, the investment case study did not include expenditures at health units such as hospitals and primary health care. Health units do not have enough decision space to determine their budget and tend to offer routine interventions, such as testing, antiretroviral therapy, or inpatient care. This study's analysis aimed to advocate for the equitable use of available resources; thus, it was more relevant to target organizations with flexibility in determining their programs.

Conclusion
In this study, a comprehensive HIV/AIDS budget is examined in Bandung City. The method has yielded a comparatively detailed estimate, based not only on the name of the intervention but also on its aim (even if the term "HIV/AIDS" is not specifically within the name of the intervention). Throughout 2016, 2018, and 2019, the budget allocated for prevention increased significantly, most likely under the influence of the PRISMA project. Despite a decrease in government funding between 2016 and 2018, this shift holds promise for reducing HIV infection, issues such as a persistently large share of donor funding for HIV/AIDS, as well as the more fragmented design of the HIV/AIDS interventions (as opposed to their integration with other programs), should be addressed to ensure sustainability.