1. Ani Shakarishvili, MD UNAIDS Country Coordinator in Ukraine AIDS 2012, Washington, DC – 23 July, 2012 Ensuring the financial sustainability of the national AIDS response in a low-middle income country with the growing HIV epidemic: is it feasible in the next few years in Ukraine?

2. Overview  Context  Money now: from where? for what?  Money in the future: predictability? how much more needed?  Possible solutions  Is it feasible?

3. Context Low-middle income country with growing and fragile economy: GDP per capita $2,974 (2010) Growing HIV epidemic: most severe in Europe: estimated 0.8% HIV prevalence (15-49 yrs) highly concentrated in key populations at risk: PWID (22% HIV prevalence), FSWs (9%), MSM (6%) National HIV response scaling up with some pockets of success (PMTCT, young/recent PWID) Changing political environment, yet some openness around social issues at national and local levels Health care reform slow, with only some benchmarks Source: Ukrainian AIDS Centre

4. Annual AIDS expenditures (in USD) by programme areas and sources of financing – 2009-2010 USD millions Total 2009: USD 65.4 M Total 2010: USD 72.8 M Source: Ukraine National AIDS Spending Assessments, 2009 and 2010

5. Number of patients on ART and contribution of the state budget and the Global Fund – 2003-2011

6. ART coverage of the estimated needs in selected countries, 2010 > 80% 60% - 79% 40% - 59% Congo Guyana Lesotho 20% - 39% Algeria India Lithuania 0% - 19% Egypt Tajikistan Ukraine Brazil Ethiopia Romania Botswana Rwanda Slovakia

7. Cost (in USD) of 1 st and 2 nd line ARV regiments – 2008-2010

8. Reported number of persons receiving opioid substitution treatment and the national targets – 2008-2016 Source: Ukrainian Institute of Public Health Policy Research, 2011 National AIDS Plan – 2013 target Current need USD 11M from the GF R6 (2007-2012) GF R10

9. Annual future financial allocations for HIV by source and the annual financial gap (in USD) – 2012-2015 Funding gap: USD 138M Source: National Operational Plan 2011-2013; Ukraine Gap Analysis Report, 2010

10. Financial sustainability - possible solutions (1)  Increasing domestic investments:  Programmatic priorities  Equitable resource distribution  Policy and practical initiatives aimed at reduction of costs per client:  Radical changes and optimization of procurement  Efficient service delivery modalities (cost and implementation efficiencies)  HIV service integration and decentralization: -Across HIV interventions -Synergies with other vertical and non-HIV programmes -Into primary care

11.  Still required donor-funding commitments (post Y2015!)  Alternative modalities of financing:  Cost-sharing arrangements ???  National health and social insurance ???  Taxation ???  Facilitating public-private partnerships ??? Financial sustainability - possible solutions (2)

12. Is it feasible?

13. Total health expenditures, percent (%) of GDP – 2007-2010 Percent Health expenditure per capita (current USD) – 2007-2010 USD Only 0.7% of health expenditures go towards HIV in Ukraine!

14.  Financing  Service delivery  Institutional  Human resources  Social sustainability Sustainability

15. Acknowledgements Co-authors: Kateryna Sharapka UNAIDS Ukraine Dr. George Gotsadze Curatio International Foundation Alexei Ilnitski UNAIDS Ukraine Prof. Natalia Nizova Ukrainian AIDS Centre Oleksandr Zhyhinas Ukrainian AIDS Centre Other colleagues: Paolo Belli The World Bank Dr. Volodymyr Kurpita All-Ukrainian Network of People Living with HIV Robert Greener UNAIDS Geneva

16. Thank you! Дякую!