партнеров региональной Were we are with harm reduction funding? New environment factors for HR funding   Завершающая встреча партнеров региональной кампании "Женщины против насилия" Ganna Dovbakh, EHRN

Key Issues Transition from international donors’ support to domestic funding Governments are not ready to allocate resources for preventive programmes targeting PUD Effective mechanisms to purchase services from non-government provides are needed at central and municipal levels

A Farewell to Donors USAID/PEPFAR – downsizing service delivery/commodity procurement portfolio GIZ – limited TA RCNF – advocacy and networking on regional level OSF – transitioning TA Netherland – TA, capacity building, advocacy GF supports 95% of harm reduction services, but it is shrinking: From 2015 to 2018 country allocations cuts was up to 40% in most of countries

GF: Reduction in country allocations From 493,915,090 in 2015-2017 to USD 297,928,391 in 2018-2020 A six-country survey conducted by the Eurasian Harm Reduction Net- work (EHRN) reports access to needle and syringe programs (NSP) ranging from 11.7% of people who inject drugs in Georgia to 37% in Tajikistan and 37.5% in Belarus; only Kazakhstan, which reports reaching 59.2%20 of all PWID with NSP in 2013, approaches the WHO-recommended coverage levels of 60%. Access to opioid substitution ther- apy is even more limited, with access ranging from 0.3% in Kazakhstan to 10.6% in Lithuania – falling far short of the ideal of 40% coverage of all opioid users that is recommended by WHO.

Does state feel need in harm reduction? Healthcare systems, especially in post-soviet countries, are medicalized Healthcare systems, in the current design, cannot reach vulnerable groups Harm reduction is not understood as а gateway for PUD to social and medical care Harm reduction is not integrated to systems

Readiness to sustain harm reduction interventions Albania 19% Montenegro 25% Romania 31% Bosnia and Herzegovina 33% Macedonia 47%

Needle and Syringe Program funding from domestic sources, % of the full demand Committed domestic funding for needle and syringe programs in 2016-2018 $14 142 176,00

Committed domestic funding for opioid substitution treatment programs Opioid substitution treatment funded from domestic sources, % of the full demand Committed domestic funding for opioid substitution treatment programs $17 808 361,00

Why commitments are not followed? Services are not “legalized” as state obligation There is no standardization of services and its costs No working mechanisms to procure services from NGO Money are on municipal level, not on national Lack of quality monitoring and assurance systems Funding In most countries reviewed for this report, specifically in Former Soviet Union (FSU) states, harm reduction programs have been introduced and financially supported by international donors. Currently national funding for OST and NSP is fully available only in EU member states – Estonia, Latvia, Lithuania and Slovakia. In all other cases the Global Fund to Fight AIDS, Tuberculosis and Malaria currently is a single major funding source for these programs in the region. However, the Global Fund has been revisiting  its  priorities and funding policies and has been gradually withdrawing from the region of Central and Eastern Europe and Central Asia. Therefore, many countries have engaged in the process of transition from Global Fund funding to national funding for HIV and TB programs. Sustainability of these programs has been a top priority in the agenda of transition process. Experience accumulated in relation to sustainability of donor funded programs, and the results of Global Fund withdrawal from Albania, Romania, Bulgaria, Estonia, Montenegro, Russia and Serbia suggest that this will be a very challenging process and there are considerable risks to the sustainability of HIV programs in the region. In the environment of ever-limited funding and too many competing priorities for scarce public health resources, harm reduction interventions, still subjects of political and ideological controversy, seem to be the most vulnerable to these risks. These programs were affected in the first place in countries from which GF has withdrawn (partially or fully). Where national strategies and proposals for Global fund’s new funding model are being developed and include transition related strategies, harm reduction programs, in particular needle and syringe programs are the only programs with very low or no projected domestic contributions - they range from 0% in Georgia to just 1.6% in Tajikistan, and 15% in Moldova. Currently national funding for NSP in these and many other Global Fund supported countries equals to zero. It is likely that many countries transitioning from GF will not be able to fully meet all necessary preconditions to sustain the developed HIV prevention programs, including harm reduction, at an adequate level of coverage. In Serbia following the end of global fund support critical harm reduction interventions such as NSP, condom distribution, community outreach, targeted informational materials distribution have been discontinued. In Romania the departure of Global fund has resulted in reduction of harm reduction services - the number of NSP sites dropped from 7 to 3 in 2014, and the number of OST sites reduced from 13 in 2013 to 8 in 2014. NSP services survived only in the capital city, Bucharest. In Albania the number of NGOs providing services to PWID fell from four to two. As of beginning of 2016 NSP service is provided only in capital city Tirana to some 80-150 PWID. By the time of Global Fund’s Round 5 grant closure in 2012 this service was available to more than 4,100 clients. Starting from 2015, the Global Fund has reduced its financial support to Russia for about 30%, which immediately resulted in a dramatic decrease in the coverage of the key populations by the essential services. The total number of HIV prevention projects among PWID, SW and MSM has dropped down from 62 to only 19. The annual coverage of PWID by harm reduction services decreased from 66,351 in 2014 to 25,390 in 2015, or for 62%. It has been increasingly recognized that income level and disease burden are not sufficient indicators to measure readiness of countries to graduate from Global Fund funding. Perceived ability to pay, expressed in GNI per capita, is hardly sufficient to measure development and sustainability. It does not indicate an adequacy of current allocations to the health sector or access to health services, nor does it reflect adequately governments’ readiness to scale-up investment in the health sector, including HIV and TB. Furthermore, even relying on economic health indicators may be misleading if funding for a given service category and/or coverage by specific intervention is unacceptably low. Even if domestic contributions to HIV/AIDS funding have been steadily increasing, HIV prevention among PWID is currently funded at a very low scale, or not funded at all from domestic sources in a majority of countries. Coverage by these services, in particular by OST, is extremely low in all countries reviewed in this report, except for Slovenia. In strict terms, whatever the economic indicators might suggest, a country cannot and should not be considered as ready for transition if coverage of populations in need by prevention and/or treatment services is far below the level that would make impact on a spread of HIV epidemic. If the role of Global Fund is in achieving a sustainable impact then there cannot be alternatives to the levels of coverage that would allow controlling the epidemics. In majority of countries included in current report HIV incidence has been steadily increasing. Along with economic indicators, lower burden of disease is seen as a condition that puts a country in a better position to assume greater responsibility for funding programs following the end of Global Fund support. At the same time, low burden can play a demotivating role in the process of prioritization. Too often governments tend to focus on instant solutions for current big problems rather than adopting rational and informed decision making and long term planning. Regardless of the income level and spread of the epidemics, we need to look at how much countries are willing to allocate for HIV/TB and work with governments to make those allocations adequate. As a rule governments are more willing to fund pharmaceuticals and ARV treatment, rather then prevention. They are much more willing to support public health systems, rather than services delivered by civil society organizations. Regional experience suggests that in too many cases governments declare their commitment to sustain GF funded HIV prevention programs, but fail to make relevant allocations from national budgets to support these programs. At least Albania, Bulgaria, Montenegro, Romania and Serbia present clear cases of such failures. Another negative consequence of transition process is a closure of community based non-governmental organizations that have been engaged with Global Fund supported program implementation. For example in Kazakhstan in 11 regions NGOs are not any more engaged in harm reduction provision. Public health institutions - AIDS Centers, now implement these services. The transition has resulted in reduction in a number of outreach workers and in a closure of component of social support (social escorting), which has been essential component of the care provided by NGOs. In a number of countries political and economic crisis has negatively affected HIV plans and funding (Bulgaria, Serbia, Macedonia, Montenegro, Romania bad example, Ukraine). In Ukraine 11 OST sites located at the currently occupied territory of Crimea and the city of Sevastopol were shut down in May 2014 and 800 OST patients remained without treatment; dozens have died. There was a program launched in May 2014 supporting temporary relocation of OST patients from Crimea and from the zone of the military conflict on South-East of Ukraine, where frequent OST medications stock outs put in danger health and wellbeing of hundreds of patients. More than 200 OST patients have been relocated, supported and remained on OST under this initiative. The remaining services for PWID in Crimea includes HIV testing and counselling, distribution of informational materials and needle exchange. GNI per capita (formerly GNP per capita) is the gross national income, converted to U.S. dollars using the World Bank Atlas method, divided by the midyear population 33

We need new arguments “Drug Users' Phobia” and dysfunctional repressive drug policy need to have working and effective alternative in harm reduction services Rational arguments on Harm Reduction as proven to be cost-effective need or individual stories of people need to be accompanied with practical calculation of short term benefits for local budgets

We need new actions Engage in each step of budgeting process on national and municipal level – not just demand money in national programs Develop our health financing and public health capacities Develop sustainable system of quality control and assurance from professionals and communities Embrace your destiny – service provider or “watchdog”