Stakeholders in Russian Federation grapple with how to do more with less
Four years ago this month, the Global Fund rescinded approval of a Round 10 TB proposal from the Russian Federation (see GFO article). The country coordinating mechanism had submitted the proposal. All stakeholders wanted to see the proposed programs implemented except for the government. The Global Fund said that if the government was not on board, the Fund was not prepared to fund the proposal.
The government had decided that it did not need the support of The Global Fund anymore to implement HIV and TB programs. So, for the last few years, the Russian Federation has not received any new grants, except for a small HIV grant funded under the NGO rule (see below).
The CCM was dissolved in 2013. In 2014, the Russian Federation pledged $60 million to the Global Fund’s fourth replenishment cycle. Thus, the Russian Federation was transformed from a recipient to a donor. The transition away from Global Fund financing is being done without any planning.
There were concerns that certain populations – particularly sex workers, persons who inject drugs, and men who have sex with men – would be adversely effected by the Fund’s withdrawal because these populations have received few or no services from the government, largely due to the fact that they are highly stigmatized by society and by the government itself.
Since the Fund’s inception in 2002, the Russian Federation has received five HIV grants worth $378 million. With the Global Fund withdrawing, the major concern was not whether the country had enough money to provide ARV treatment or prevention (it did), but rather whether it would provide these services to SWs, PWID and MSM given its negative attitude towards these populations. All three groups are criminalized and/or face restrictive regulation. Obviously, these constitute significant barriers to accessing services.
Moreover, the NGOs providing services to these populations faced human right challenges of their own. Opioid substitution therapy is illegal, and there are restrictions placed on needle exchange and condom distribution, despite that the fact that all three approaches are internationally recognized as being effective. In additional, restrictions were placed on the ability of NGOs to conduct advocacy work financed by international donors.
Because of these problems, in 2014 The Global Fund provided an $11 million HIV grant to the Russian Federation under the NGO rule. The proposal was submitted by two NGOs – the Russian Harm Reduction Network (now known as ESVERO), and the Open Health Institute (OHI). The grant is currently being implemented by OHI. No funds have gone to the government. One objective of the grant is to improve access to HIV prevention, treatment and care services for key populations in Russia. Another is to empower these populations and to fight for the removal of legal barriers.
However, the NGO grant was significantly smaller than previous grants. The concept note indicated that the proposed programs would only support the provision of services to 5% of the estimated population of PWID, 7% of MSM and 6% of SWs in selected regions.
The Russian Federation has one of the highest HIV rates in the Eastern Europe and Central Asian region. In 2013, the country officially registered 77,896 new HIV cases and prevalence rate was 479 per 100,000 population. The epidemic is concentrated mostly among key affected populations, but transmission through heterosexual contact is on the rise.
Developing the concept note for the NGO HIV grant was not an easy process. All stakeholders were aware that it would be the last tranche of money from The Global Fund. The challenge was how to do more with less. A country dialogue was organized. Some participants wanted to continue providing services as before. Others thought this was not the best use of the last bit of funding from the Fund. They argued for placing more emphasis on empowering communities, advocacy and removing legal barriers to accessing services.
The country dialogue participants elected a coordination committee (CC) with mostly similar functions as a CCM, but consisting mainly of community and NGO representatives without government participation. The CC was responsible for concept note development.
Recognizing that the HIV grants was to small to make a significant difference to prevention services among key populations, the CC changed the program’s direction to empowering key effected populations. The plan was that these populations would ignite and drive a dialogue between communities and government, and begin the task of removing the existing legal barriers. The CC believed that this approach would produce better and more sustainable results in the long term. This was not easy decision and involved extensive discussions and debates among the stakeholders (see GFO article). The Global Fund Secretariat supported the approach adopted by the CC.
Today, the main function of the CC is to oversee the programs being implemented with the HIV grant.
Two years after the first country dialogue discussions, there is a consensus that the approach that was adopted was the right one, and that it has already produced results. For example, in February, the Ministry of Health initiated a discussion concerning developing a framework document for the national HIV/AIDS strategy. The MOH placed a document on its website and invited feedback from NGOs providing services and from other experts. While the NGO community has been advocating for this type of collaboration for years, the approach taken by the HIV grant almost certainly helped.
In April, SWs organized a forum in Moscow aimed at developing a 5-year strategy and identifying core group of activists for further training. Similar forums are planned for PWID and MSM in the coming weeks. These forums show that key populations are becoming more empowered.
Currently, a group of experts and NGO representatives in the Ministry of Economic Development is working on developing the costed list of HIV prevention services to be included in federal budget. CC has been actively involved in this work even though it does not have any official status. The ministry has already developed a plan for how state funds can be made available to NGOs providing social services. Finding ways to enable the state to fund NGOs to provide services is an essential element of any plan to transition away from Global Fund support in the Russian Federation.
Discussions are underway now about how the transition should happen. While there is a agreement that community empowerment and removing legal barriers are key priorities in the transition, there is no consensus yet on how to achieve this. Both the CC and the PR of the HIV grant, OHI, have undertaken initiatives.
For example, the CC is monitoring the HIV program implementation and putting a lot of effort into ensuring efficiency. Meanwhile, CC members are trying to raise more funds to expand activities being supported by the Global Fund. And OHI is undertaking activities to promote general tolerance towards NGOs by the government officials, most of whom do not completely understand the role of NGOs in managing the HIV epidemic.
As well, OHI and the CC, and others, are developing a report documenting best practices in prevention and treatment programs worldwide.