On 5 September, the recently elected government of the Republic of Macedonia ordered the Ministry of Health to allocate 103 million Macedonian denars (approximately € 1,674,000) within the National HIV Program for 2018 to (a) ensure continuous access to antiretroviral (ARV) treatment for HIV-positive people; and (b) support the implementation of HIV prevention programs among key affected populations (KAPs) such as men who have sex with men (MSM), persons who inject drugs (PWID) and sex workers (SW). This amount is nearly four times bigger than the amount that had been budgeted for 2018 by the previous government. Local activists consider this development to be a very important step in ensuring the sustainability of HIV services in Macedonia.
According to Arben Fetai, Senior E.U. Policy Advisor for Stop AIDS Alliance, one of the key factors contributing to this achievement was the personal commitment of the new Minister of Health, Arben Taravari, who has introduced multiple initiatives to restore citizen’s trust in the health system. Fetai said that the new government, which was elected on 3 June after a two-year-long political crisis, is resolutely pro-European and reformist, a total break with the previous government which ran the country for eleven years amid corruption scandals and under-investment in social sectors.
Fetai said that the Minister took this decision in his third week in office, during his first meeting with civil society representatives – “a great example of budget advocacy at work.” Unfortunately, he added, Taravari has been requested by his party to run for Mayor of his hometown in local elections scheduled for 22 October. Taravari has communicated that he won’t come back to the Ministry whether he wins the election or not.
“That means that there will be a new Minister of Health on 23 October,” Fetai stated. “Although the new minister will belong to the same political party, it is not a given that he or she will be supportive in the long term of the initiatives that Taravari was pursuing. Continued engagement will therefore be very important.”
In an email published on the European AIDS Treatment Group (EATG) listserv on 7 September, Andrej Senih, an HIV activist from Macedonia and a member of the EATG, said that the decision of the government is very important for two reasons. First, it obliges the Ministry of Health “to establish by the end of 2018 a functional long-term mechanism for financing the activities of the National HIV Program targeting key affected populations that are implemented by civil society organizations (CSOs).” Importantly, the major part of the allocated funding, 60 million denars (about € 1 million euros), is designated to support HIV prevention services that CSOs are delivering to these key populations. This amount is more or less at the same level of annual funding that was previously available for programs implemented by CSOs with Global Fund support in the last few years. So, no major decrease of funding is expected.
Second, this is the first official and formal government document to express a clear commitment to support civil society–based HIV prevention activities and to lay out the precise steps to ensure the sustainability of HIV services for key affected populations (KAPs) in the country.
Petition on harm reduction and prevention
In a related development, in June of this year, HOPS (Healthy Options Project), a major HIV prevention NGO service provider in Skopje, launched a petition calling for harm reduction and HIV prevention programs to be maintained in Macedonia. The petition was addressed to the Ministry of Health and the Government of Macedonia. According to the petition, the continued survival of harm reduction and HIV prevention programs in Macedonia is uncertain because the current financial support from the Global Fund ended in June 2017. The petition said that this could endanger 17 harm reduction programs operating in Macedonia, which have proved their effectiveness; and this could, in turn, result in over 10,000 people who use drugs as well as their family members being left without proper social and health care. Hristijan Jankuloski, Executive Director of HOPS, told Aidspan that given the latest developments, there is reason to believe that a successful transition of HIV services for KAPs from Global Fund support to national funding will take place in Macedonia.
The decision by the Macedonian government guarantees that the new funding for HIV treatment and prevention, which had been submitted by the Ministry of Health in the draft versions of the 2018 budget, will remain during the rest of the budget planning cycle for 2018 (which is likely to take another 1-2 months). Even more important, said Andrej Senih, is that the commitment can be considered as formal recognition by the government of the HIV epidemic among KAPs in Macedonia, and of the role of CSOs as key partners to reach out to KAPs and to provide them with much needed HIV services.
Funding gap in 2017
Now, community activists and CSOs are waiting for the Ministry of Health to announce an open call for NGOs to apply for funding, as there is a need to urgently disburse funding allocated for the prevention activities among KAPs for 2017. This will fill a gap that remains from now until the end of December (although some funding is also still available within the current HIV Global Fund grant which recently obtained another no-cost extension until the end of 2017). A public procurement mechanism will be used, and only NGOs will be eligible to apply, but it is not clear yet how it will work in practice. A lot of work remains to be done to pilot this mechanism and to ensure that it is functional and accessible to NGOs working in the area of HIV prevention among KAPs. Also, the detailed planning of the activities within the 2018 National HIV Program needs to be done through a consultative process with CSOs that are key implementers of prevention programs.
But there are also other gaps in Macedonia’s transition-related processes that need to be addressed. In the opinion of Jankuloski, who is also the Chair of the country coordinating mechanism (CCM), one such gap is related to the governance of the national HIV response. The Macedonian CCM is not a formal body and probably will not continue its work after Global Fund support ends. For this reason, Jankuloski said, it is important to strengthen the National HIV Commission and make sure that this structure, first, inherits from the CCM its multi-stakeholder composition (to make sure that KAPs and NGOs have a voice in the decision-making processes) – and, second, is not just a consultative body of the MOH, but rather has decision-making power concerning program and budget matters, and also has an oversight function similar to what the CCM has.
Another gap mentioned by Jankuloski is related to human resources, as the MOH has never worked with NGOs directly before. As well, the people currently working in the Project Implementation Unit – the structure which is responsible for implementing the programs funded by the Global Fund in country – officially are not MOH employees and will probably leave as soon as the Global Fund grant comes to an end.