UHC in Ukraine: how to stop services from shrinking
In our series of articles assessing progress towards UHC implementation, we hear activists from Indonesia, Kenya, South Africa, Ukraine and Vietnam on the challenges facing marginalised groups affected by HIV and the actions they are taking in the battle to ensure UHC truly leaves no one behind.
“We are now at a middle point,” says Anton Basenko of the Alliance for Public Health. “By January 2020 services will be 80% domestically funded. I’m optimistic, but at the same time pragmatic, realistic. I think 2020 will be challenging for us, and 2021 is currently unknowable.”
In Ukraine, debates around universal health coverage (UHC) are closely linked with wide-sweeping health reform and the partial withdrawal of Global Fund support. In the Global Fund’s new grant cycle, which began in January 2018, Ukraine is gradually transitioning activities and procurements from non-government organisations (NGOs) to the government-run Public Health Centre, by 20% in 2018, 50% in 2019, and 80% in 2020. But there are concerns that, when state funding becomes the main source of support for people most affected by HIV, some essential services will be lost. “The biomedical is likely to be prioritised because it can be more known, more measureable,” says Anton. “Bureaucratic systems of funding are more at ease with the procurement of medications than the procurement of specific social services or peer services. But we live in a country with an HIV epidemic that is concentrated among key populations, the biggest of which is people who inject drugs, and these groups need specific services that go beyond the biomedical – outreach work, harm reduction work – it is all necessary.”
I was one of the first substitution therapy patients in Ukraine and I know how important these services are – not only the distribution of medications but the support of social workers and psychologists or the attention of doctors or nurses who work on opportunistic infections.
Of the nine HIV services recommended by the World Health Organization for people who inject drugs, it is likely only four will be funded under Ukraine’s state budget: needle and syringe procurement and distribution, HIV counselling and testing, tuberculosis (TB) screening and rapid Hepatitis C tests.
“That’s it,” says Anton, “no overdose prevention, no Hep B vaccination, no social and legal counsel, no information and education materials, no other equally important parts. Even with the needle and syringe procurement we don’t know what the quality of these medical items will be, and we are concerned.”
National versus local funding
Activists in Ukraine have raised the issue of shrinking services with Ukraine’s Ministry of Health and have been told that local health budgets will be expected to fund non-biomedical services, such as psychosocial support.
“Historically the health system in Ukraine was budgeted 20% state and 80% from local budget, and for many years the Global Fund gave money to the local level as well, so in some senses I can understand this position,” says Anton. “But by 2020 that Global Fund support will not be there.
I am absolutely confident that… the prioritisation and actualisation of the problems people who use drugs in the regions will come very far down on the list, in comparison to the social problems of, say, older people, children, veterans.
“In the very best case scenario I think some regions we will run small psychosocial support programmes, say for five or ten people, but that will be it. But we have around 350,000 people who inject drugs, and even at current levels only 12,000 people receive comprehensive OST services.”
A changing political landscape brought about by recent presidential and parliamentary elections in Ukraine will undoubtedly affect marginalised communities further but exactly how remains unclear.
My prediction is that by 2020 we will lose almost all psychosocial support for key populations. But it does depend on who will be in the new cabinet and how active civil society and affected communities are in advocating against this.
Four key areas
For Anton, the challenges arising from the shift to publically funded and delivered health services fall into four broad categories.
“The first is legal – the criminalisation of certain key populations – which automatically means a lack of access to official medical institutions,” he explains.
“The second is financial, as funding is being provided to medical institutions rather than NGOs or community-based organisations, which is problematic when we know certain groups are only successfully reached if those providing services come from the same communities.
“The third is about infrastructure. Our official medical infrastructure is not prepared to take over the delivery of specialist services for HIV, TB, Hep C – particularly in small towns and rural villages. Also, when it comes to small towns or villages, where everybody knows each other, there are issues around confidentiality.
“The fourth is ethical. From annual research we can see that stigma and discrimination against LGBT people, sex workers and people who use drugs is still high among the general public and this applies to some medical staff as well.
That is why you cannot divide human rights, stigma and discrimination issues from the idea of UHC. These issues all have to be part of the UHC advocacy agenda.
In 2017, representatives from three key population groups – people who inject drugs, sex workers and men who have sex with men – joined Ukraine’s Country Coordinating Mechanism (CCM). This not only monitors and coordinates Global Fund grants, it is also the official advisory-consultative body to the Ukrainian cabinet on HIV, TB and viral hepatitis. Regional ‘sub-CCMs’ also exist and now have key population representation.
Anton says the fact that key populations are meaningfully engaged with key decision-making processes in Ukraine suggests their voices will be heard in debates around health reforms and UHC. But although these structures are in place, a key part of the jigsaw is missing because many community activists are still unaware of the need to engage with the issue of UHC. This, says Anton, is where the Partnership to Inspire, Transform and Connect the HIV response (PITCH) is playing a vital role.
“PITCH held a meeting in April to discuss UHC and it was really timely – nobody really understands what’s going on with this area – only people who are deeply involved or special experts on UHC do.
What PITCH is enabling us to do is to make the link between health reform and UHC. It has also very clearly shown how partnerships can be built successfully, and why including the expertise of civil society in governmental processes is important.
The HLM: shaping future advocacy work
PITCH partners in Ukraine now plan to focus on the UHC High Level Meeting as a jumping off point that will shape future discussions and advocacy on UHC.
“Because the new parliament and cabinet will only begin at the end of August, the official HLM delegation will need to be formed quickly,” explains Anton. “We are currently putting our asks together for this and hope to be involved in the delegation.
“Our plan is to see what comes from the UHC HLM, and what kind of political document and obligations will be taken up by member states. Ultimately, these obligations are about accountability as they are something we can hold officials to.
From the HIV movement we know how important it is for civil society and communities to be organised. We also know how important it is for civil society and government to work in partnership together. The mobilised, organised movement that came out of the need to respond to HIV was incredibly done – and this is something which should be used in Ukraine as UHC continues to unfold.
Anton's call to action
To ensure UHC works in Ukraine, Anton and other Ukrainian activists are calling for:
- UHC, as a term, to be simplified.
- The UHC movement to be popularised.
- The key affected communities to be included in reaching and monitoring UHC goals.
- Government accountability.
- Low-threshold, human-rights based, gender-sensitive and -focused health services for the most marginalised in society, people on low-incomes and others who are usually left behind.
- Effective, transparent and flexible approaches to UHC with obvious involvement of community service organisations, because funding, as such, is not a ‘magic bullet’.
Anton Basenko is the country focal person for PITCH and is openly living with HIV. Alongside his work for the Alliance for Public Health, Anton sits on the board of the International Network of People Who Use Drugs and the Eurasian Key Populations Health Network. He is also a member of the Communities Delegation of the Global Fund Board and represents people who use drugs on Ukraine’s CCM.