Daniil Kashnitskyi, Research Fellow of the High School of Economics. Expert of ECUO PLWH
I have been working in the HIV response area for the last ten years with just a few short intervals: first in Russia, then in regional projects of Eastern Europe and Central Asia. During these years of work, I collected plenty of stories about successful innovative community projects which later would inexorably fade out after the withdrawal of donors. All of them had a rapid start and plummeted down shortly.
Communities, concerned experts and specialists accepted as an axiom and succumbed to the fact that international donors enter the countries to help, teach, and then leave. We have learned the mantra of sorts, that the Global Fund to Fight AIDS, Tuberculosis and Malaria is reducing its support for programs in middle-income countries.
Decrease of the EECA financial support
Indeed, the Global Fund is rapidly cutting down for Eastern Europe and Central Asia, from $ 500,000 dollars in 2015-2017 to $ 300,000 million planned for 2018-2020.
First of all, prevention and support programs for key populations, for prisoners and migrants, are being cut down. Some consider this to be fair, some are indignant, but almost everybody conceded to the fact that this process is inevitable. There is another mantra – the transition to national funding, but I will focus on that a bit later.
I re-read my first paragraph and I want to write down the word “responsibility” somewhere, but, alas, I cannot find a right place for it.
A case to shatter illusions
In 2013 in Kazakhstan, when switching to national financing of antiretroviral therapy, 2000 HIV-positive foreign migrants were simply de-registered from therapy lists, thus becoming deprived of access to treatment. Yes, it reduces costs and workload, at the same time making the country statistics figures look prettier. By the way, a significant proportion among those two thousand were permanent residents, who simply did not have a Kazakhstan passport for various reasons related to the post-Soviet specifics. And there are no formal grounds for criticism, because the state seems to have no obligations towards them. But who is responsible for those whom they accustomed to help?
Yes, sometimes they are ready for dialogue, sometimes they are not. Decriminalization of key groups is failing to make its way through the legislative barriers, the conservative discourse increasingly dominates over HIV prevention programs. They do not want the communities to be visible, they do not consider us to be people capable of making decisions. It is simpler and more comfortable to test hundreds of thousands of students than to empower community-based organizations to conduct rapid testing on their own, even although the latter is more efficient at times.
According to UNAIDS data for 2016 in Eastern Europe and Central Asia, 51% of new HIV cases were attributable to people who use drugs, 6% to men who have sex with men, and 6% to sex workers. The sexual partners of representatives of key groups account for other 33%. What proportion of new cases in our region are among the general population? 4%! (while globally the general population accounts for 64% in the structure of new cases).
These data are the most eloquent and unambiguous testimony (no, a real alert) of persistent systematic ignoring of key groups in national HIV programs!
Our region is the only one in the world where the epidemic continues to grow rapidly. Since 2010, the number of new cases has increased by 60%. Every second press release on HIV topic for the past month would start from this phrase.
Another heartrending figure
80% of new cases in the Eastern Europe and Central Asia region occur in the Russian Federation. Whether we like it or not, but until the Russian Federation starts paying attention to the needs of key groups and fundamentally changes its HIV policies, the chances for changing the epidemiological situation in the entire region are very scanty. Russian politicians and MPs in the meantime prohibit sexual education programs in schools, discriminate against the LGBT community, and refuse to accept evidence of the effectiveness of substitution treatment in HIV prevention among people who use drugs. Considering the intensive migration processes in the post-Soviet area, it is Russia’s HIV policy that will define the future of the HIV epidemic in the entire region, whether we like it or not.
Against this backdrop, in December 2017, the Global Fund fully closed funding programs in the Russian Federation. We, in fact, cannot demand anything, we have to take this for granted. And we again repeat the mantra that the Global Fund (and, afterwards, other donors) support poor countries, while Russia has long ceased to be considered poor.
Another example from Kyrgyzstan
The Global Fund allocated $3.7 million for 2018 to fund HIV programs, which is 34% less than in 2016. The funding gap is still $ 1.5 million despite all possible savings. Will the national budget allocate these funds? The officials and politicians express their commitment, but considering the inevitable failures in other countries and all the objective factors of instability and unpreparedness (for example, legislative framework for the social contracting system and HIV-servicing NGOs operation are not enacted), the outlook seems very disturbing. I would like to wish communities of Kyrgyzstan to have even greater solidarity and steadfastness in the struggle for health and the right to recognition.
Those who supported us and backed us up are leaving rapidly. The cargo plane landed and the cargo plane took off, while we are still on our ground.
At regional meetings and round tables, I hear the same narrative from time to time that the donors’ withdrawal is inevitable and even fair in a certain aspect. Indeed, if you look at economic indicators, they seem promising: GDP is growing, the region is getting richer, the readiness for takeover to national financing has been assessed in most countries of the region. Apparently, it’s time to take care of ourselves.
In such a national-oriented narrative, we, the community representatives, are placed on the same level as the decision-makers in our countries. But a gap between us did not become narrower, and the dialogue is fragile and quite short.
Governments, as far as possible, take responsibility for financing antiretroviral therapy. The examples of Russia and Kazakhstan prove that this is possible. But with regard to prevention programs, it is obvious that there is some kind of ideological stumbling block between us and our governments, which apparently will need many years to overcome it.
We take for granted those narratives rooted in the national state building era
In Russia the GDP at purchasing power parity per capita is $ 23,000 (according to the World Bank), but how the communities can benefit from it, if we are deprived of access to vital services and the right to respect and safety? We hardly can consider this average economic indicator to be somehow related to us, it has little to do with our daily routine, while donors rely on it when planning their priorities, though with reservations. For what reason?
On the other hand, I would like to challenge the ethical foundation of the assumption about the inevitability of the international donors withdrawal. In the era of aggravating economic inequality, when 1% of the population concentrated 42% of the world’s wealth in their hands, and this trend is only growing, why not think about long-term donor funding for programs for key groups? It can be seen as moral commitment of the powerful of this world towards those less advantaged.
It is necessary to continue work with governments and demand the sustainable financing of programs in the field of HIV, tuberculosis and hepatitis C, to promote the decriminalization of key groups, to foster the evolution of post-totalitarian MPs and national officials. Perhaps, the elites will gradually change, and we will live to see the triumph of tolerance and humanism … And if we do not live long enough to see it? Therefore, it is necessary to act today in all areas and realistically assess the chances.
“Warming up” of national funding
Therefore, in addition to “warming up” the national funding, I see the potential for more active involvement of private foundations in long-term financing of programs for key groups in Eastern Europe, Central Asia and around the world, both through replenishment of the Global Fund and through other humanitarian organizations. It is very important that we have confidence and the right to convince donors of the need for long-term responsibility for those whom they accustomed to accept help (I promised to write about responsibility).
Actually, the concept of responsibility will remain skewed, if we do not talk about the urgent need for us, the communities of the region, to become professional in fundraising, partnership building and openness.
We are empowered to shape and create narratives
We are able to generate narratives of transnational involvement and create an atmosphere in which prosperous people of the world, well-founded communities and successful cities will fulfill their potential and take moral responsibility for those who still need support and whose health and dignity are held hostage by national systems.
Donors are increasingly welcoming dialogue with communities. It is important for us to get involved on an equal grounds, not as beggars, but as providers of information possessing a sense of right and responsibility, to increase our visibility, and try to deconstruct the discourse based on blending the nationally-oriented approach and the inevitability of international donors’ withdrawal.