A comparative study of opioid substitution therapy protocols will contribute to the sustainability of harm reduction in the Eastern Europe and Central Asia region
The new methodology for the funding allocations and consequent gradual decrease of GF financing for the Eastern Europe and Central Asia (EECA) countries puts at special risk the operations of harm reduction services, which were, traditionally, largely supported by the GF.
Although the HIV epidemic in EECA is mostly concentrated among people who inject drugs- PWID, the government’s spending on harm reduction programs is paradoxically low. For example, Georgia covers 51% of the program expenditures, Kazakhstan provides 34%, Uzbekistan-18% and Belarus-14%. The rest of the countries cover from 0 to 8% of total expenditures for the harm reduction services. Only a few countries, which are EU member states, are providing 100% of domestic funding for harm reduction services (more information is available here).
The main reasons why the governments concerned might not take over the services established and run by the Fund are the limited health care budgets or unwillingness to support PWID, or both. Most governments in EECA either do not acknowledge drug use as a public health issue, or are simply avoiding making unpopular political decisions, such as supporting stigmatised minorities (for example, by increased funding and/or by liberalising restrictive drug policies). The governments’ position, in general, is reflection of the population’s negative attitude towards drug users.
The Global Fund-supported regional program “Harm reduction works-Fund it!”, implemented by Eurasian Harm Reduction Network (EHRN), aims to build enabling environment for strategic-public and donor-investments and to increase the capacity of PWID in advocating for own rights, including increased domestic funding for PWID services.
The program has recently published a comparative study of opioid substitution therapy (OST) protocols conducted in six EECA countries: Belarus, Georgia, Kazakhstan, Lithuania, Moldova and Tajikistan. The study looked at OST protocols in each country and compared them to the practices applied in Western countries, such as Germany, USA, Canada, Austria, Switzerland and Australia. The particular areas of the focus were OST practices during pregnancy, policies on taking doses individually, taking them due to illness, travel or other reasons, specific driving licence procedures for PWID, and suspension from the OST program.
The study identified the challenges of OST programs in EECA and explored how similar challenges were addressed by developed countries. Comparison will inform developing of the national standards for OST, which should lead to optimisation of harm reduction programs. The Program Manager, Lela Serebryakova has specifically emphasized that “The term optimisation should not be understood as the cutting of something down. To us [EHRN team] optimisation is to make services efficient, equitable and to increase the quality.”
Although the main advocacy message of the program is directed to the governments, requesting to provide or to increase the domestic funding for harm reduction programs, its approach is complex, yet innovative and constructive. The program has already produced two outputs, which could provide precise estimation and justification for requesting a larger budget: 1. The methodology to access the harm reduction funding levels, with tools to track actual expenditures and unit costs per client per year; and 2. Evidence for developing the national standards of OST services. Used together, they can estimate how much money is required to ensure high quality services to PWID.
The EHRN program actively involved the PWID communities in the research process, which educates and empowers them. Equipped with the evidence and tools, they are not only able to request for increased domestic funding, but could also justify, how much resources do they need for services and why.
The Global Fund supports issue-based NGOs to empower PWID in order to transform them into equal partners of the state in decision-making processes. The scarce financial resources, the lack of relevant knowledge and stigma are just part of more complex and inter-linked problems. Increased domestic funding and/or improved policy will not automatically have positive impacts on the quality of life of drug users.
The Eurasian Harm Reduction Network (EHRN) supports the communities with necessary knowledge, tools and practice for the battle with the national governments. Ms Serebryakova told Aidspan, “EHRN supports communities to formulate evidence-based advocacy strategies for their national challenges. Although we are not in the position to directly influence any national processes, we still try to be instrumental in these processes”.
In January, the program is delivering training for the community and government representatives on how the outcomes of the research can be operationalized and incorporated into the national monitoring and evaluation systems.
The changes in harm reduction policies and funding are very slow. Most problems, which we described in GFO article here are still unchanged. However, the Global Funds Sustainability, Transition and Co-financing policy has stimulated innovative, complex and responsible approaches to program designs. The harm reduction services are inspected by PWID communities who believe that although money is important, in the case of the harm reduction services, it is the quality of the program itself which means more.