Audit of Grants to Ukraine
24 January 2018
Ukraine has made progress in accelerating the end of HIV and tuberculosis as epidemics. AIDS-related deaths have halved since 2010; the price of antiretroviral drugs to treat HIV have been brought down thanks to concerted efforts by civil society; and the government has increased its financial commitment for HIV and tuberculosis programs. However, significant numbers of people diagnosed with HIV are still lost to treatment; approximately 9000 people with HIV have not started treatment yet due to a shortage of drugs; multidrug resistant tuberculosis success rates are low; and there is limited visibility on how the government will transition out of Global Fund grants over the next two years.
Ukraine has the second biggest HIV epidemic among Eastern European and Central Asian countries. It is also one of the countries with highest burdens of multidrug resistant tuberculosis, ranking fifth in the world. The Global Fund classifies the country as a challenging operating environment. Since 2014, the economy has shrunk on average 8-10%; this is compounded by conflict in the eastern regions of Donetsk and Luhansk.
Despite the difficult economic and geopolitical situation, HIV programs have been scaled up. The number of people on antiretroviral treatment increased from 64,360 in 2015 to 82,860 in 2017. However, with scale-up comes treatment cascade challenges. Many people who test positive are lost to treatment. Current outreach programs yield low case detection results from key populations such as sex workers, men who have sex with men, and people who inject drugs, where the epidemic is concentrated. A combination of limited drug availability and an overloaded health workforce hampers the ability to put people on treatment.
Although treatment success rates for multidrug-resistant tuberculosis are gradually increasing, improvements are needed in case management and the development of sustainable patient-centered services. The Global Fund has financed a new approach which involves home visits for patients rather than clinic trips, which has had some success in reducing the risk of cross infection in hospitals. However, the approach has not so far been extended to the majority of patients. Nor can its effectiveness be proved as there is no comparable data.
The audit also called for improvements in implementation and procurement arrangements. By 2020, most disease program activities will transition out of the current NGO grant recipients to the Public Health Center, a government entity under the Ministry of Health. However, a plan is needed to address the impact of the transition on the access and the range of services available to key populations.
Antiretroviral drug costs have gone down significantly thanks to civil society advocacy and negotiations with manufacturers. However, some key drugs are still more expensive compared to international generic reference prices. Government procurement delays, exacerbated by a funding crisis in 2014/2015, have resulted in consistent “borrowing” of drugs financed by the Global Fund or grant savings being used to procure drugs for government-supported patients. As Global Fund investments decrease over the next grant cycle, the risk of drug stock-outs in the HIV program increases.
To address the above issues, the Global Fund is putting in place a number of corrective actions in collaboration with the country partners including an optimization plan to increase treatment impact; better coordination between government and donors to avoid any future overstocking or stock-outs; and a detailed action plan to ensure satisfactory quality and access of services by key populations after transition.