Slide1: The effects of the Global Fund to Fight AIDS, Tuberculosis and Malaria on equitable access to HIV/AIDS services at the sub-national level: Ukraine and Kyrgyzstan Neil Spicer1, Gulgun Murzalieva2 and Tetyana Semigina3 1London School of Hygiene and Tropical Medicine, 2Centre for Health System Development, Kyrgyzstan, 3Kyiv Mohyla Academy, Ukraine Country studies funded by the Open Society Institute STUDY AIMS Purpose of the study The study assesses the effects of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) on the health systems of Ukraine and Kyrgyzstan at the sub-national, and aims to provide timely and relevant information for policymakers at the national and international level. Study objectives To assess the effects of the GFATM on equitable HIV/AIDS service accessibility To identify the institutional/programmatic factors and household/community factors that determine HIV/AIDS service accessibility. The Global HIV/AIDS Initiatives Network The Ukrainian and Kyrgyz studies form a part of the Global HIV/AIDS Initiatives Network. The Network was established in 2006 to track the national and sub-national effects of the major global health initiatives for HIV/AIDS (GHIs): the Global Fund to Fight AIDS, TB and Malaria, the United States President’s Emergency Plan for AIDS Relief and the World Bank’s Global HIV/AIDS Programme (including the Multi-country AIDS Programme). Network countries undertaking 2-4 year studies are Angola, Benin, China, Ethiopia, Georgia, Kyrgyzstan, Malawi, Mozambique, Peru, South Africa, Tanzania, Uganda, Ukraine, Vietnam and Zambia. Key themes include the effects of GHIs on sub-national scale-up, health systems capacity and equitable access to HIV/AIDS services. STUDY LOCATIONS Three sub-national regions were sampled for detailed analysis in Ukraine and Kyrgyzstan (Table 1). Table 1 Regions sampled for analysis: Ukraine and Kyrgyzstan METHODS National level analysis Semi-structured interviews with national level stakeholders in Ukraine and Kyrgyzstan sampled purposively including representatives of health and public administration agencies and international donor agencies Analysis of relevant policy and programmatic documents including legislative/ regulatory documents Analysis of official statistical data Sub-national level analysis Facility survey data from a sample of GFATM sub-recipients: government health facilities and non-governmental organisations (NGOs) (Ukraine N=12, Kyrgyzstan N=24) Semi-structured interviews with sub-national level stakeholders sampled purposively including health officials and managers of government health facilities and NGOs (Ukraine N=71, Kyrgyzstan N=38) Structured interviews with frontline staff of sampled facilities and organisations (Ukraine N=88, Kyrgyzstan N= 32) Structured interviews with clients receiving HIV/AIDS services including those from high risk groups (Ukraine N=93, Kyrgyzstan N=60) FINDINGS 1. GFATM-financed HIV/AIDS programmes in Ukraine and Kyrgyzstan Ukraine - Received a GFATM Round One grant ($23M), and a Round Six grant has been approved ($151M) - 2,766 people receiving GFATM-financed ARVs by 2006 (only 65 people receiving ARVs prior to the GFATM programme) - More than 100,000 injecting drug users (IDUs) received preventative services through the GFATM programme (by 2006) - 14,000 sex workers (SWs) received preventative services (by 2006) Kyrgyzstan - Received a GFATM Round Two grant ($17M) - 69 people receiving ARVs (2007) - 7,750 IDUs receiving harm reduction interventions (2007) - 3,500 SWs receiving GFATM-financed services (2007) 2. Distribution of GFATM programme resources in Ukraine and Kyrgyzstan Emphasis on preventative services e.g. harm reduction, drug dependency reduction programmes, condom supply, social marketing High numbers of NGOs are GFATM sub-recipients focusing on HIV prevention Key target groups: IDUs, SWs, men having sex with men (MSM) and increasingly prisoners, young people and other groups Programmes focus on high-prevalence regions: capital cities, south and east Ukraine, south Kyrgyzstan Problems scaling up sufficiently to address rapidly growing demand for HIV/AIDS services KEY MESSAGES Scale-up of GFATM-financed HIV/AIDS programmes is substantial in Ukraine and Kyrgyzstan but insufficient to meet growing demand for preventative services GFATM programmes in Ukraine and Kyrgyzstan reproduce existing inequalities in HIV/AIDS service distribution Complex, inter-related barriers to accessing HIV/AIDS services exist at the local level reflecting health systems, political, legislative, socioeconomic and cultural contexts Despite legislative reform in Ukraine and Kyrgyzstan stigma, discrimination and criminalization of high risk activities remain important barriers to utilising HIV/AIDS services Whilst the GFATM finances HIV/AIDS information materials in Ukraine and Kyrgyzstan low levels of awareness of issues relating to HIV/AIDS, service availability and eligibility to use services remain 3. Barriers to using GFATM-financed services at the sub-national level Ukrainian and Kyrgyz clients’ perceptions of the most significant barriers to receiving HIV/AIDS services are show in Table 2. Table 2 Barriers to receiving HIV/AIDS services: Ukrainian and Kyrgyz clients’ perspectives* 4. Barriers to using GFATM-financed services at sub-national level: key issues from client, provider and stakeholder interviews Stigma, the criminalization of drug use and sex work and discrimination among HIV/AIDS service providers Stigmatisation of HIV/AIDS, IDUs, SWs and MSM was reported by clients as the most significant barrier to using services in Ukraine and Kyrgyzstan: clients fear using a service will result in their status being revealed to family or community members Policing criminalized activities - especially drug use - is also an important factor: harassment of IDUs was reported to be widespread and constitutes a barrier to using HIV services for a high proportion of clients, especially in Ukraine There is evidence of discriminatory practices among some staff such as withholding commodities and levying informal user changes, and problematic client-provider relations, especially among government health workers, although substantial variation between different services: this leads to a reluctance among some Ukrainian clients to use services; the problem is less acute in Kyrgyzstan Poverty A relatively low proportion of clients indicated that the payment of fees to receive services affects their ability use HIV/AIDS services reflecting the fact that clients are in principle eligible for free HIV/AIDS services delivered by GFATM sub-recipients in Ukraine and Kyrgyzstan However, poverty is problematic for some client groups in both countries: implications include difficulties meeting costs of travel and paying informal user changes, and potential loss of income whilst using services Information and knowledge Low levels of awareness of issues relating to HIV/AIDS, the availability of services and eligibility to use services constitutes an important barrier to the utilisation of HIV/AIDS services, especially among Ukrainian clients GFATM finances information materials in Ukraine and Kyrgyzstan but there are problems reported reaching some marginalised groups, and problems delivering culturally sensitive information using accessible language in Kyrgyzstan Distribution of resources and geographical factors It is difficult for some GFATM sub-recipients to address growing demand for preventative services: shortages of resources/commodities mean than some organisations have difficulties balancing quality of interventions for individual clients against quantitative coverage in a context increasing levels of need A relatively high proportion of clients responding to the Ukrainian survey indicated that perceptions of quality were a barrier to utilising services; a lower proportion of Kyrgyz clients identified this as a problem There are considerable regional variations in distribution of GFATM-financed programmes in both countries: there are problems of geographical access especially in smaller towns and rural areas Organisation of HIV service delivery and coordination between services There is a lack of transparency among some government and NGO GFATM sub-recipients: some evidence of commodity leakage and sale for profit in Kyrgyzstan (e.g. condoms, needles/syringes), and limited transparency in recording activity levels Whilst complex bureaucratic processes for accessing government services exist they only represent barriers to HIV/AIDS service use for a minority of Ukrainian and Kyrgyz clients Limited coordination between GFATM sub-recipients, especially in Kyrgyzstan results in ad hoc client referrals. However, relatively few clients indicated that problems of referral between services were a barrier to service use FURTHER INFORMATION AND CONTACT Global HIV/AIDS Initiatives Network www.ghinet.org Neil Spicer, London School of Hygiene and Tropical Medicine neil.spicer@lshtm.ac.uk * Factors described as having a moderate, strong or very strong impact on clients’ abilities to access the service they are currently using. ** Percentages of clients responding to each question.