The Global Fund expects Ukraine to do more with less.

As reported previously in GFO (here and here), Ukraine received a total allocation of $184.6 million: $137.3 million for HIV and $47.3 million for TB. The entire allocation is for existing grants and must last through December 2017.

In its letter of 12 March informing Ukraine of its allocation under the new funding model (NFM), the Global Fund Secretariat acknowledged that the $137.3 million for HIV was less than expected, and less than requested in September 2013 as part of its Phase II request. The letter said that Ukraine will need to find innovative ways to maximize impact.

Following a 25-26 March visit by Grant Management Division head Mark Edington, another letter established Fund expectations for a concept note that will “prioritize essential, high-impact activities, targeted to highest-prevalence regions.” The letter signed by Edington added that the Fund would like to see continued scale-up, “even if at a reduced rate.”

These objectives will require difficult choices, particularly in the current difficult climate of political instability, Edington acknowledged. “We expect [Ukraine] to seek efficiencies and cost reductions primarily from non-essential activities,” according to the letter, a copy of which was shared with Aidspan. “We encourage the CCM to reduce overheads, program administration and human resource costs at the PR and SR level, and to phase-out top ups and incentives in the health system.”

Ukraine’s slate of prevention and harm-reduction activities that target the most vulnerable groups has contributed to a steady decline in HIV transmission among people who inject drugs: the group with the highest prevalence rate in the country. At the same time, government resources for treatment have increased; the number of people on government-funded anti-retroviral treatment in 2013 has more than tripled since 2009.

These gains cannot be sustained without a continued increase in government funding, Edington said, and additional resources committed to activities targeting men who have sex with men (MSM), sex workers and the prison population.

Edington also offered suggestions to enhance Ukraine’s fight against TB, the spread of multi/extensively drug resistant TB (M/XDR-TB) in particular. Universal access to timely and quality diagnosis and adequate treatment of all forms of TB, while switching from a hospital-based to an ambulatory-based model of care, was first among his recommendations.

Future Global Fund support for TB activities in Ukraine is contingent on implementation of  recommendations from the joint Global Fund-USAID-WHO mission conducted in May 2013, which called for a revision of the national TB treatment protocol, improvement of the models of TB care, and a restructuring of the governance of the national TB program. These recommendations must be implemented before Ukraine submits its concept note in June 2014.

Ukraine’s notional allocation for HIV, as determined by the NFM formula, would have been $31 million for 2014–2016. Over the past four years, Ukraine has received $169 million. Applying the principle of graduated reductions, the Global Fund allocated $137.3 million. This means that Ukraine was over-allocated by 435%. The graduated reductions represent an effort by the Global Fund to re-balance its portfolio so that ultimately all countries receive their fair share.