Decisions, Decisions, Decisions: Behavioural Economics Willingness and ability of OST clients to pay for some OST services in Odesa region in the light of Ukraine crisis Liudmyla Khomych, Deloitte Consulting Overseas Projects LLC, USAID Project “HIV Reform in Action”, Kyiv, Ukraine Strengthen Ukraine’s health system to ensure effective and sustainable delivery of HIV/AIDS prevention, care and treatment services to key populations. “No conflicts of interest to declare”

Outline Background Methodology Results Conclusions and Next steps

Background – Ukraine The second-highest HIV prevalence rate in Eastern Europe 238,000 PLHIV (2016)1 Key populations – HIV prevalence2 (IBBSs 2015): PWID - 21.9%; FSW - 7.0%; MSM - 8.5%. KPs size estimations2: 346,900 PWIDs 80,100 CSWs 181,500 MSM Sources: 1Spectrum 2IBBS 2015 – Alliance for Public Health

Background – Ukraine (cont.) OST programs (as of June 1, 2017): 9,615 OST clients 177 OST sites 2.8% out of estim. # of PWIDs Бупренорфін 1031 Метадон (рідкий) 449 Метадон 8135 Source: OST Program Data, available at http://phc.org.ua/pages/diseases/opioid_addiction/stat-docs Alliance for Public Health, http://aph.org.ua/uk/pro-nas/napryamy-roboty/zamisna-pidtrymuvalna-terapiya/

Background – Ukraine (cont.) Funding sources for OST programs 2013-2015 Бупренорфін 1031 Метадон (рідкий) 449 Метадон 8135 Source: UNAIDS, Ukraine NASA reports for 2013-14, 2015

Background (cont.) Potential financial reduction of the international donors’ support for OST programs The state financing of OST (and other) programs in Ukraine complicated by economic crisis. Building and piloting a sustainable model for the provision of critical services to KPs and PLHIV at the rayon/city level. The implementation of the alternative financing models such as co-payment is optimal way to secure critical for PWIDs services. Piloting - in each of the 7 targeted oblasts Russian annexation of Crimea Crisis in eastern Ukraine Economic crisis (Hryvnia devaluation)

Financial devaluation of hryvnia (in more than 3 times!) Are there willingness and ability of current OST clients to pay for some OST services? Rhetorical question! Financial devaluation of hryvnia (in more than 3 times!) Financial devaluation of hryvnia (in more than 3 times!)

Odesa region Dnipro Mykolaiv Cherkasy Odesa Kyiv Poltava Kherson

Odesa region One of the highest HIV burden in Ukraine Concentrated HIV epidemic Key populations - HIV prevalence1 (IBBSs 2015): PWID - 27.5%; FSW - 9.5%; MSM - 12%. KPs size estimation1: Odesa The international donors’ support of OST programs for PWIDs are currently in the process of financing reduction. The economic crisis in Ukraine complicated the nationwide state financing of OST programs in Ukraine. The implementation of the alternative financing models such as co-payment is optimal way to secure critical for PWIDs services. The aim of the study is to assess the willingness and ability of current OST clients to pay for some OST services. 38,300 PWIDs 7,700 CSWs 11,900 MSM Sources: 1IBBS 2015 – Alliance for Public Health

Odesa region (cont.) 2 OST sites – Odesa city (AIDS Center, TB clinic) 1 OST site – Izmail city (Izmail Central Municipal Hospital) 418 OST clients 1.1% out of estim. # of PWIDs Sources: OST Program Data, available at http://phc.org.ua/pages/diseases/opioid_addiction/stat-docs Alliance for Public Health, http://aph.org.ua/uk/pro-nas/napryamy-roboty/zamisna-pidtrymuvalna-terapiya/

Methodology Study design: cross-sectional Study timeframe: summer 2016 Study population: current OST clients in Odesa city Random sampling strategy Structured questionnaire Univariate and bivariate analysis (to estimate correlates of clients’ willingness to pay for some OST services)

Results – Basic characteristics Study sample (current OST clients), N=161 Sex: male, % 77.6 Average age, years (SD) % before 25 years 41.98 (8.0) 0.6 Marital status: not married (single), % 49.7 Education: secondary, % 66.5 Regular employees, % 29.2 Income medium/not rich (self-reporting), % 43 Salary as a main source of income, % 57 OST duration (more than 12 months), % 73.9 A total of 161 clients of OST programs (125 (77.6%) males and 36 (22.4%) females) were interviewed. The average age of the respondents was 41.98 years (SD=8.0). 66.5% of interviewed OST clients in Odesa city had a secondary education and 14.9% had a higher education. Half of the respondents (49.7%) had a single marital status. 74% of respondents uptake OST program for more than 12 months.

Results – Willingness to pay Study sample (current OST clients), N=161 Perceived benefits: “possibility to uptake additional medical care at OST site”, health improvement, reducing financial burden Correlates P-value income per family member 0.009 self-assessment of financial well-being 0.008 perceived social support 0.014 <200 UAH (89.5%), 200-500 UAH (9.8%), 2001-3000 UAH (0.7%) Overall 89% of respondents (n=143) demonstrate willingness to pay for some OST services in Odesa. The willingness to co-pay for some OST services is higher among clients listed “possibility to uptake additional medical care at OST site” as personal benefit of OST participation. The willingness is also correlated with income per family member (p=0.009), self-assessment of financial well-being (p=0.008) and perceived social support (p=0.014).

For what OST clients are ready to pay Study sample (current OST clients), N=161 To receive therapy (drugs) for a few days, % 80 To take therapy (drugs) at the nearest HC facility for a few days, % 65 Anonymous, % 41 To buy drugs in the pharmacy, % 35 To increase daily dose, % 24 To replace methadone, % 18 Overall 89% of respondents (n=143) demonstrate willingness to pay for some OST services in Odesa. The willingness to co-pay for some OST services is higher among clients listed “possibility to uptake additional medical care at OST site” as personal benefit of OST participation. The willingness is also correlated with income per family member (p=0.009), self-assessment of financial well-being (p=0.008) and perceived social support (p=0.014).

For what OST clients are ready to pay Study sample (current OST clients), N=161 To receive therapy (drugs) for a few days, % 80 To take therapy (drugs) at the nearest HC facility for a few days, % 65 Anonymous, % 41 To buy drugs in the pharmacy, % 35 To increase daily dose, % 24 To replace methadone, % 11 Overall 89% of respondents (n=143) demonstrate willingness to pay for some OST services in Odesa. The willingness to co-pay for some OST services is higher among clients listed “possibility to uptake additional medical care at OST site” as personal benefit of OST participation. The willingness is also correlated with income per family member (p=0.009), self-assessment of financial well-being (p=0.008) and perceived social support (p=0.014). >200 UAH

Conclusions Clients of OST program in Odesa region demonstrated willingness and ability to pay for some OST services despite on economic crisis in the country. 200 UAH is the modal amount per month. Their willingness depends on socio-economic status of PWID and his/her family. These important correlates of willingness and ability to pay should be considered for design and implementing OST co-payment service delivery model in Odesa region.

Next steps OST costing per patient per month (regional-sensitive methodology) Developing alternative OST co-payment models Policy development on OST co-payment models Introducing an alternative models in the region. Service 408 948 UAH Methadone 540 Adapted: M. Duda at the National AIDS Conference 2016, Ukraine

Acknowledgements Co-authors L. Khomych1, O. Yaremenko1, O. Postnov2, N. Avaliani1, M. Duda1 1Deloitte Consulting Overseas Projects, LLC, USAID Project HIV Reform in Action, Kyiv, Ukraine,  2Ukrainian Research Antiplague Institute named after Mechnikov, Odesa, Ukraine Funding PEPFAR USAID Ethical approval IRB at Ukrainian Institute on Public Health Policy, Kyiv, Ukraine IP in Odesa region Natalia Davydenko Natalia Kitstenko, Illia Podolian, Yevgen Bratsun, et al. Other partners Alliance for Public Health National Public Health Center under MOH of Ukraine ОБФ «Шлях до Дому» КУ «Одеський обласний центр профілактики та боротьби зі СНІДом»; БФ «Веселка» КЗ «Міська клінічна лікарня №10» м. Одеси; ОБФ «Шлях до Дому»

Thank you! Дякую! Contacts: Liudmyla Khomych M&E and SI Advisor, HIV Reform in Action Project, Kyiv, Ukraine Deloitte Consulting Overseas Projects, LLC Office (+380) 44 281 23 66 E-mail: info@hivreforminaction.org, lkhomych@hss-share.net.ua Skype: Lyuda Khomych https://www.facebook.com/liuda.khomych www.hivreforminaction.org www.facebook.com/HIVReformUA/