Ukraine: Surviving Global Fund transition to safeguard the HIV response
As Ukraine transitions towards domestic funding and leadership of its HIV response, the voice and influence of key populations, communities and civil society is more important than ever. Not only through their meaningful involvement in decision-making at all levels but also in securing funding to deliver their grassroots programs: programs that are now under threat by the transition process.
Community-led advocacy and monitoring of the availability, accessibility, acceptability and quality of nationally-funded HIV services is key to success. Ukrainian civil society organisations (CSOs) working in the HIV response have been have been at the heart of advocacy efforts to ensure this through their membership of PITCH, the Partnership to Inspire, Transform and Connect the HIV Response.
PITCH was the first large-scale HIV programme to invest solely in community advocacy
PITCH partners support marginalized people to change the services, law, policies, practices and mindsets that affect their everyday lives. Knowing communities hold the key to bringing about changes to the services, laws, policies, practices and mindsets that affect them is one thing, but a lack of understanding among governments and donors means the value of community-led advocacy is not always recognised. PITCH has sought to change this. The five-year, nine-country programme has worked with four marginalised and vulnerable groups most affected by HIV ― adolescent girls and young women; lesbian, gay, bisexual and transgender (LGBT) people and men who have sex with men (MSM); people who use drugs (PWUD); and sex workers (SWs) ― to strengthen and connect community-led advocacy. It has supported community advocates to: bring about equal access to services for HIV and sexual and reproductive health and rights; further equal rights for marginalised people; and develop and strengthen the skills, organisational structures and resources needed to carry out effective advocacy, generate evidence and improve policies and practices in the HIV response.
PITCH has worked in nine low- and middle-income countries in Africa, Asia and Eastern Europe, all with high HIV prevalence: Indonesia, Kenya, Mozambique, Myanmar, Nigeria, Uganda, Ukraine, Vietnam and Zimbabwe. It has supported over 100 community-led organizations, networks and platforms, including regional partners in Eastern Europe and Central Asia (EECA) and Southern Africa. It also works through its global advocacy partners, including International Civil Society Report/Free Space Process, International Drug Policy Consortium and Harm Reduction International.
The challenge in Ukraine
Ukraine has the second-largest HIV epidemic in EECA, with 250,000 people living with HIV (PLHIV). There has been a huge increase in the use of antiretroviral drugs (ARVs) in recent years but the high rate of new infection threatens to outpace these gains.
In 2018, Ukraine started its transition from international donor funding to domestically funded HIV prevention, care and support programs, and this is largely seen as a positive step by community organizations. Nonetheless, there have also been many challenges.
Anton Basenko is the Country Focal Point for PITCH – which in Ukraine has been hosted by the non-governmental organization the Alliance for Public Health – and is a member of the Community Delegation to the Board of the Global Fund. He describes the transition as ‘the opening of Pandora’s Box’. According to Basenko, “This is a change in funding from Global Fund to domestic sources, but it also requires changes to be made to the legal framework and to practices.” Since 2003, Ukraine has received $82 million from the Global Fund. A significant focus of those grants has been to build up strong communities as advocates for sustainable, evidence-informed and rights-based responses.
Basenko cites the procurement and quality of ARVs, opioid substitution therapy (OST) and the provision of a full package of high-quality support services throughout the country as significant challenges emerging from the transition.
Another is ensuring the continued funding, meaningful involvement and a voice for CSOs as the government takes on full leadership of the HIV response. These organizations – representing key populations and communities – have played a pivotal role in tackling HIV throughout the era of Global Fund support.
Andrii Chernyshev is the Head of Advocacy and External Communications for Alliance Global, an NGO working in the HIV field and representing MSM. “The transition from donor funding to public funding should be the most progressive innovation in recent years,” says Chernyshev. “However, existing problems and challenges that accompany this transition make it very difficult to obtain funding for organizations of key communities, including MSM. For example, there is currently only one LGBT organization providing HIV prevention services among MSM with public funding.”
Evgenia Kuvshinova is the Executive Director of Convictus Ukraine, another of the five PITCH partners in Ukraine. Convictus is one of the country’s biggest service providers for key populations. She adds: “The transition plan is one of the biggest issues. It has two sides. First, it is the best story in our region that Ukraine is using national funds. But we see another side: it is a very big issue for CSOs which provided services supported by the Global Fund and are now financed by the government. We are required to change our registration and pay a 20% tax. We have to change our organizations and become business organizations, but we are not a business. The transition plan is only about a basic package of services but, if we want to give key populations the package they need, we need to combine the support of international donors, government and communities.”
Changes in the way HIV organizations work
This huge shift in the ways and means of funding HIV programs in Ukraine has brought a significant repositioning of organizations working in the sector.
The advocacy focus has moved to the national level, with lobbying of the Public Health Centre, the government body coordinating HIV budgets and responses and the Principal Recipient for the reducing Global Fund contributions.
“All key population networks, CSOs and partners of PITCH are advocating at different levels.” says Basenko. “We have different working groups under the Ministry of Health; and we use these groups to advocate for quality drugs. We are advocating to extend the lists of services, not just the basics. We are forcing them to deal properly with the transition period.”
Kuvshinova adds: “For us it is really important to use advocacy to provide special recommendations about bridging gaps and what we need to do in the provision of HIV services – and so we go to national ministries and national authorities.”
Key populations represented on the Country Coordinating Mechanism (CCM)
PITCH has also been central in advocacy and campaigns to the Global Fund at the Secretariat level, explains Basenko. Vital to this has been increased CSO representation on the CCM.
In Ukraine, the National Council on HIV and TB doubles as the CCM. It is a national consultative committee under the cabinet of ministers that submits funding applications to and oversees grants from the Global Fund; and coordinates other initiatives to combat HIV and TB.
A number of advocates now sit in the group, representing the rights of MSM, PWUD and SWs from their respective networks.
“We all understand the Global Fund has powers of influence and can put political pressure on governments in the countries it is funding,” says Basenko. “PITCH’s first success was ensuring representatives of three key populations joined the CCM – only PLHIV had been there before.”
Significantly, PITCH also has a representative on the independent oversight committee, which monitors the work and actions of the CCM. Basenko adds: “This is very much a success – it’s very valuable. We are there. Government representatives have to acknowledge us and discuss with us all these decisions. You have got to include key populations in decision making.”
Chernyshev adds: “It is crucial to take into account the interests and needs of key groups when planning advocacy activities to increase community access to quality HIV health services and to involve their leaders as much as possible in working groups and coordination mechanisms. The work of all advisory bodies needs to be made more transparent, especially to attract funding for the provision of services for MSM and other groups.”
Kuvshinova says her role on the CCM is 'very important’, giving CSOs unprecedented high-level access to cabinet ministers. “Two years ago, all positions on the CCM were held by government people,” she says. “Behind our inclusion in this process during the transition period is the PITCH program, supporting CSOs representing key populations to have a stronger voice.”
Local advocacy and funding are increasingly important
As well as securing representation on the CCM, there has been a focus on the 25 sub-CCMs in different regions of Ukraine, not only to ensure that the voices of key populations are heard at local level but also to lobby regional governments for vital funds for HIV services.
“We should be present in these local bodies, have this opportunity to participate at the local level. We are advocating for local budgets,” says Basenko. "PITCH invested in training to help representatives of different key populations to be more effective: how to work properly in these coordination councils, how to work with bureaucrats, how to formulate your expectations and to press for decisions.”
Kuvshinova explains: “Through the PITCH programme we started working very closely with local authorities. We are trying to develop our relationship and access some local funding. We have some results – Convictus opened a centre funded by domestic finances. If we have local funding, we have stability.”
The visibility of the MSM/LGBT community at the local level has also increased. “Thanks to successful work with local authorities and local deputies, it was possible to obtain preferential premises for the provision of services for MSM which ensured the continuity of the provision of HIV services for MSM” says Chernyshev and adds: “PITCH has permitted us to establish strategic partnerships at local level with allies, such as human rights organisations, HIV service NGOs, organisations of other key communities, health facilities and other entities.”
It is clear that the visibility of key populations and PLHIV communities, their influence and meaningful involvement in decision making at all levels has greatly increased with the support of PITCH.
PITCH has been one of the main sponsors of the annual National LGBTI Conference, the largest event for Ukraine’s LGBTI+ community.
It has also supported national advocacy to amend the Criminal Code to deter crimes motivated by intolerance, including those related to sexual orientation and gender identity, and responsibly regulate laws around drug possession and use.
The program has also backed a ‘leadership school’, helping youth leaders to develop their skills and knowledge of HIV so they can better participate in national discussions. PITCH has encouraged close cooperation between its partners and the national media in Ukraine, an important step in changing prevailing public opinions about HIV and key populations.
‘In the next three years, we will definitely see improvement’
In this critical transition phase, Basenko says, PITCH has been ‘a flexible and complementary’ program, providing training and capacity building in monitoring and evaluation for all its partners on the ground and nurturing trust between CSOs, communities, government bodies and funders.
“There is still much to do to win the fight against HIV, but PITCH has done really fantastic things, helped us form great partnerships to get funding. With more time, over the next three years we will definitely see improvement; which would not be possible without PITCH. Sex workers, LGBT, PWUD – each key population discusses and delivers their own processes. But now we are dealing as one army, one constituency – that was the work of PITCH.”
When the Ukrainian government recently put pen to paper on its latest country agreement with the Global Fund for a grant of $136 million, Anton Basenko was in the room. His was one of only four signatures on the documents. It was truly a landmark moment for community representation in the battle against HIV in Ukraine.
“With this agreement we are signing, we are involved in this process. It means we know what is there and we are helping to deliver this grant proposal together,” says Basenko. “Our insight will be there. We will be able to put our stamp on it.
“The Global Fund must be as proactive as possible with the Government and be very clear in addressing the role of civil society during transition. Global Fund programs always aim for high quality standards and those standards must be very strictly controlled in the transition. We all realize that, even if the Government starts covering all services and treatment formerly funded by the Global Fund, it definitely will not pay for advocacy – which is considered as ‘opposition’ to them. The Global Fund has to leave specific funding streams for civil society, especially community organizations, during and after transition.”