The concept note delivered on 8 September for Russia's last HIV grant from the Global Fund was a perfect illustration of the conundrum facing a growing number of Eastern European/Central Asian countries: how to do more with less to fight a widening HIV epidemic.
As more countries from the region 'graduate' from Global Fund eligibility due to their income classification, the funds that they could once count on to support prevention, harm reduction and other programs targeting vulnerable populations are disappearing. And there is little evidence that most national budgets are prepared or able to fill the vacuum.
In Russia, the situation is complicated by the decision by government to dismantle the country coordination mechanism and to restrict operations by foreign non-governmental organizations. The application of the NGO rule by the Global Fund is a way to operate within these restricted parameters, but the $11.9 million allocated for HIV through 2017 will represent the last-ever Global Fund grant to the country -- even as HIV infection rates continue to rise.
All-too-aware of the implications of this scenario, Russian NGOs set themselves to work, holding a country dialogue session on the margins of the May 2014 EECA AIDS conference. Despite the decision to boycott the conference by a number of NGOs, more than 100 representatives of local organizations attended the country dialogue session in order to prioritize the most cost-effective and highest-impact interventions and activities.
Those who attended the meeting told Aidspan that there were two distinct camps stumping for two different sets of priorities: those who considered it critical to maintain the level of service delivery, including treatment of those infected and the provision of harm reduction materials such as safe needle and condom distribution, and those who wanted to invest in advocacy to try and change national policies on harm reduction and prevention.
The decision to shift the emphasis away from service delivery towards advocacy followed a candid and lengthy discussion about the effectiveness of past programs. Many of those who participated in the country dialogue, including principal recipient Open Health Institute, avowed that needle exchange programs, counselling and other activities carried out since 2006 did not quite have the impact they had hoped for. And with a declining budget, it was perhaps time to try something innovative: a new program that combined service delivery with advocacy campaigns to overcome legal barriers to wider, government-supported harm reduction.
Those in the other camp lined up behind the non-profit partnership known as Esvero: a group responsible for doing the harm reduction activities since 2006. If services targeting people who inject drugs are suspended, the group argued, the risk of increased transmission of HIV is even higher.
How Russian implementers adapt their programming to the constrained resource environment should serve as a model for other countries. It also provides a window of opportunity to develop a credible and comprehensive evidence base for future operations: something that was at the heart of the concept note submitted by the Russian NGOs in early September.
As donors draw down their assistance in the region, public health leaders need to create effective, and cost-efficient models that are sustainable beyond the three- to four-year lifespan of donor-assisted projects. This places a greater financial and operational burden on governments -- but also gives them the time to do it, and to develop and nurture collaborations with NGOs to assist in carrying out work at the community level.
According to OHI, this will also give community organizations the tools they need to empower key populations to, in the future, protect their own rights -- to transform from beneficiaries into partners.
But Esvero's executive director Pavel Aksenov, considers this to be a risky choice, this trading of services for advocacy and the possibility that no matter how much time, energy and money are invested in transforming the policy environment, there could be insurmountable opposition from the state, never a great friend to junkies. And then the trade-offs will have come with a heavy price: a failure to stem the epidemic and a yawning gap that there is no one to close.
Nailya Vinongradova, of OHI, is aware of the risks of doing something different -- but she is also aware of the risks that accompany a less-than-effective status quo. All eyes will now be on Russia to see if the trade-off was the right one.