Gaj Gurung is a Research and Policy Analyst at Harm Reduction International where he leads projects to support national advocacy for harm reduction funding. Before this, he coordinated Youth LEAD, the largest young key populations network in Asia and the Pacific, representing them on many high-level delegations and international platforms.

Harm reduction is heavily reliant on international funding in many countries. Overall, this source is shrinking and for some countries, income status and disease burden limit access. Domestic support for harm reduction has increased over the past decade, but rarely funds a comprehensive harm reduction response at scale. Governments may not direct funds to community-led, community-based or civil society organisations. There may not be a ‘social contracting’ mechanism to allow public funds to be available for non-governmental entities. Without this, the quality, accessibility and people-centredness of harm reduction programming can be missing, which ultimately, compromises effectiveness.

A literature review has established the current state of domestic financing for harm reduction, with a focus on social contracting. The various models and mechanisms employed have been collated and reviewed, along with the supportive factors and challenges for social contracting, particularly for community-led harm reduction responses within punitive drug policy contexts.

While social contracting for harm reduction remains very limited, there are positive and promising examples in some countries, often within the context of transition from Global Fund support. Thailand, for example, integrated HIV prevention and treatment for people who use drugs into the national health insurance scheme and provision is via community organisations, while domestic funding supports community and civil society service providers in Brazil and Croatia. A common limiting factor across countries with domestic funding for harm reduction was the sole management and implementation of opioid substitution therapy by governments, often resulting in low enrolment. This research brings together the prerequisites for optimal social contracting for harm reduction and presents recommendations for policy-makers for introducing and optimising domestic financing for harm reduction. It is critical that community-led, community-based and civil society organisations are funded as central providers of evidence-based, human rights-based and people-centred comprehensive harm reduction programmes.