Harm reduction in many countries in Eastern Europe and Central Asia is not sufficient, strategic, or sustainable. This is the central conclusion of an assessment conducted by the regional “Harm Reduction Works – Fund it!” program in six countries: Belarus, Georgia, Kazakhstan, Lithuania, Moldova, and Tajikistan. A report on the assessment was recently published.
Two types of assessment were conducted: a financial analysis, and a quality of services assessment. The latter was community-led, because the assessment was also aimed at building the capacity of community representatives to conduct long-term government-level advocacy campaigns for increasing domestic funding.
The major findings of the assessment were as follows:
- None of the countries meet the international guidelines for access to needle substitution programmes and opioid substitution therapy. The guidelines recommend that 60% of persons who inject drugs be reached by NSPs. Based on 2013 data (the latest information available), at 59%, Kazakhstan came close; but reach in the other countries ranged from only 12% to 38%. The guidelines recommend that 40% of all opiate users be enrolled in OST programs. Coverage in the six countries (based on 2013 data) ranged from under 1% to 11%. (Program officials do not believe that the situation has changed much since 2013 for either NSPs or OST.)
- There are wide variations among the countries in unit costs for the NSP and OST programs. While some variation is to be expected, the extent of the variation suggests that countries could be more strategic in the design and implementation of their programs.
- Service delivery methods and policies are not consistently oriented around community needs. The most common problems identified in the assessment were the unavailability of community outreach workers; the unavailability and the poor quality of NSP commodities; the lack of access to HIV rapid testing; and the lack of access to take-home doses of methadone for OST clients.
- Programs do not adequately address the special needs of women and youth. Survey participants identified a lack of access to gender-sensitive programs, and a lack of female outreach workers. They also identified age-restrictions as a barrier to access by youth.
- There are significant legal barriers to accessing harm reduction services. Examples include a restricted drug policy in Georgia; prohibiting non-medical staff from conducting rapid HIV testing in Kazakhstan and Tajikistan; and medical protocols not allowing the use of naloxone in certain countries.
- Greater investments are urgently needed to increase the coverage and quality of harm reduction services. The regional program estimates that the gap for the six countries included in the assessment is $13.6 million for 2016 alone.
The report says that each sentinel country needs to address its policy and legal barriers; and that strong regional advocacy and leadership will be needed to overcome entrenched interests that may resist change throughout the EECA. According to the report, the findings in the sentinel countries are likely to apply to many other countries in the region.
The community-led assessments revealed that there are PWID who had never heard about harm reduction approaches and programs until they were approached for this assessment.
The report contained several recommendations, including the following:
- national governments must develop plans for transitioning from Global Fund support that include significant domestic investments in harm reduction;
- the quality of existing harm reduction services should be improved; and
- national governments must remove legal and policy barriers to harm reduction programs.
In a foreword to the report, Michel Kazatchkine, UN Secretary General Special envoy on HIV/AIDS in Eastern Europe and Central Asia, said:
“The region is now at the next critical juncture: moving to sustainable harm reduction programming, fully supported by governments and owned by domestic actors. This will not be an easy transition, but it is a necessary one; many countries in the region are heading towards economic development levels that leave them ineligible for donor assistance. Harm reduction is a vital public health measure, and now is the time that governments must commit to it, to safeguard the lives of some of their most vulnerable citizens.”
The third years of the Harm Reduction Works – Fund it! program will be devoted to advocacy work carried out at the community level. The main objective of this work is to convince governments to spend more on harm reduction. The work will be informed by the results of the assessment described above.