Bosnia and Herzegovina- BiH, an upper-middle income country with low HIV prevalence rates in both the general and high-risk populations, estimated at around <0.1% and <0.5% respectively, became ineligible for Global Fund support after September 2016. In the country, possession of drugs and organization of provision of sex services are criminalized.
Same-sex relations are not criminalized but same sex marriage is nonetheless, not allowed. Stigma and discrimination against key affected populations-KAPs (Men Having Sex with Men, Sex Workers and Injection Drug Users) and Persons Living with HIV (PLHIV) are high, even among health care workers.
As a result of the Global Fund’s withdrawal from BiH, KAPs and PLHIV will be most affected. All other marginalized groups (such are Roma people, migrants and prisoners)have also lote the support and activities which were provided with the Fund's funding.
During the years of Fund support, about 60-70% of the HIV response was funded from domestic sources geared mainly towards treatment and care. Preventive services i.e. harm reduction, mobile testing of KAPs, etc. were totally funded by the Fund. Elements of HIV prevention and control previously covered by the Fund are key challenges in this post-Fund period.
The challenges on the ground
In the wake of the Fund’s withdrawal, three main challenges have emerged:
First, there are procurement challenges related to the fragmentation of the health system of the country and its inability to enter the free market via one national mechanism. Indeed, in BiH, there is no national health budget, but several budgets at entity levels and in BiH at cantonal level corresponding to the national administration structure.
Today, 20 voluntary confidential counselling and testing (VCCT) centers operate within public health institutions. Antiretroviral Therapy (ART) is available to all persons in need and treatment is carried out at the infectious disease clinics in Banja Luka, Sarajevo and Tuzla. However, ART resistance test is not available for patients because of lack of equipment and education. Second, there are delivery challenges partly related to the inexistence of laws for social contracting; consequently, civil society organizations-CSOs can receive grants from the ministries but cannot be contracted by the health care funds to provide services. Thus, most services implemented by CSOs previously funded by the Global Fund will lack continuous funding.
For instance, almost all prevention, promotional and educational activities implemented by CSOs will lack funding as well as the mobile VCCT centers and attached services. This lack of funding will also result in lack of activities related to stigma and discrimination fighting; lack of advocacy, promotion of PLHIV and KAP rights; and lack of social support to PLHIV. Also, some programs implemented by public institutions such as continuous Professional Development of the health care workers designed to address issues of stigma and discrimination will lack funding.
The third challenge is that of data collection and surveillance, because there is no systematic methodology and quality of data is often inconsistent. The presence of the Global Fund provided a framework and guideline for data collection and surveillance.
It appears then, that Bosnia and Herzegovina is not prepared for the withdrawal of the Fund.
The country needs both funding and time to help ensure that an HIV responsible transition planning process is in place. For instance, an additional period will afford the time needed to create a social contracting mechanism for the provision of preventive health, social, and educational services. These services will be offered by CSOs and be costed and budgeted by the national government.
Also, it might be important that the Global Fund help increase awareness of other international donors and organizations to the challenges faced by this country and others in similar situations and help mobilize support. This suggestion is particularly relevant for the European Union since the BiH is one of EU neighborhood countries. The European Union may be able to use its political leverage and its funding to help the BiH address also other political challenges that prevent the country from adequately responding to HIV and AIDS. Other international donors can also play a significant role in creating safety net for the key affected populations.