The impact of the Global Fund’s Eligibility Policy on access of KAPs to HIV services in Romania

Abstract: In the light of the recent approval of the Revised Global Fund’s Eligibility Policy at the 39th Meeting of the Global Fund Board this article provides an overview of the Romanian “eligibility story” and continuous attempts of Romanian NGOs to break the political barriers within the Global Fund and prove their eligibility to receive an allocation for HIV component to be able to ensure the access of key affected populations in country to the needed HIV prevention services.


The impact of the Global Fund’s Eligibility Policy on access of KAPs to HIV services in Romania

Recent revision of the Global Fund’s eligibility policy could give a chance to Romania to become considered as an eligible for HIV allocation within the next allocation period

Doing much for HIV treatment but not for prevention

The HIV story in Romania has been marked by several dramatic episodes. The first was in late 1980s, when thousands of children got infected with HIV through dramatic nosocomial HIV epidemic, predominantly among orphans and hospitalized children.[1] Then the voices of parents and many supporters led to the introduction of the country’s large treatment programs – early on with donor support – to provide HIV treatment to all in need. Today, the country spends 70 million euros for HIV treatment[2], care and support reaching universal access and covering 12,247 people with HIV out of 15,212 as on 2017 which is a great achievement.

But when it comes to prevention – “the Romanian authorities practically invest no money in HIV prevention”, says Nicoleta Dascalu, project manager from the Romanian Association Against AIDS. That is why becoming ineligible for Global Fund’s support of HIV became another dramatic episode in Romanian HIV history.

Consequence of improperly planned transition from donors’ support in Romania

At the beginning of 2010, the country, a fresh member of the European Union, was praised for reaching out to people who inject drugs and even starting a pilot of opioid substitution therapy and needle exchange in prisons. This work was supported by the Global Fund as well as by the Dutch government through UNODC. However, both funding streams stopped in 2010-2011 and the government did not take over funding for NGOs. At the same time, the drug scene also changed with emerge of new psychoactive substances that were legal but could result in up to 10 times injections a day. While the legislative and policy environment in Romania did provide for harm reduction and other services targeted to key populations to be maintained, the Government had shown little commitment to fund such interventions, especially needle and syringe programs. “Most NGOs that had implemented harm reduction services just closed them down, because of lack of funding. The only services that continued were funded, by sheer luck, with money from European Union structural funds projects, dedicated to social and professional reintegration of drug users”, remembers Nicoleta Dascalu.

HIV prevalence among people who inject drugs started growing rapidly: from 3.3% in 2009 to 27.5% in 2013.[3] It was noted in a January 2016 article in the International Journal of Drug Policy that “a specific HIV outbreak among drug users (around 2011) has been directly linked to the significant decline in harm reduction services following the Global Fund transition out of the country[4]“.

Another part of the Romanian HIV story is that HIV prevalence among men who have sex with men also became high. In the EU funded study SIALON II[5], Bucharest recorded the highest HIV prevalence among the 13 cities in study – 18%. Nevertheless, as the country’s official report on the progress of implementation of UN Political commitments on HIV[6] acknowledges, there were no real programs remaining among MSM as on 2016.

Reasons of ineligibility of Romanian HIV component for Global Fund’s support

Since 2007, there has been a requirement in the Global Fund’s Eligibility Policy that in order for UMICs to be eligible for HIV funding, they must have at least high HIV disease burden and also be on the Organisation for Economic Co-operation and Development’s (OECD) Development Assistance Committee (DAC) List of Official Development Assistance (ODA) recipients. The list includes all low, lower middle and upper-middle income countries based on GNI per capita as published by the World Bank, with the exception of those being G8 members, European Union (EU) members, and countries with a firm date for entry into the EU making them ineligible to receive ODA. This requirement is the only reason why Romania lost its eligibility to receive funding for HIV response from the Global Fund and never became eligible again since 2010 when its last Global Fund HIV grant came to an end. At the same time for some reasons this requirement is not applicable for TB and Malaria components thus Romania is eligible to receive the Global Fund funding for TB response and currently is implementing Global Fund’s TB grant. For the 2017-2019 allocation period, Romania was one of only two countries in the entire world (the second one is Bulgaria) being not eligible because of this requirement as they joined the EU in 2007.

Theoretically Romania could become eligible if it met the requirements of so called “NGO rule” – another provision of the Global Fund’s Eligibility Policy which allows for potential eligibility for UMICs that meet the disease burden thresholds for HIV but are not on the OECD DAC List of ODA Recipients. Eligibility under this rule till recently was linked to the existence in country of “political barriers” which preclude the provision of evidence-informed interventions for key populations. Funding provided under this rule must be channeled through civil society and cannot directly fund governments.

In practice the “NGO rule” to date has allowed only one country to be funded – the Russian Federation – in the 2014-2016 allocation period. Romania could have been eligible for the 2014-2016 and 2017-2019 allocation periods, but according to the Global Fund “was not deemed to have substantive political barriers that would preclude providing services to key populations”.

Attempts to influence the situation

Romanian NGOs have tried few times to prove the Global Fund their right to receive an allocation for Romanian HIV component in accordance with “NGO rule”. In 2013 a targeted application for HIV grant was developed and submitted by Romanian NGOs to the Global Fund within the “NGO rule” but was not supported because the Global Fund Secretariat has considered the situation in Romania as a result of ‘lack of funding or political will rather than political barriers’, per se[7].

Another attempt was made in 2016 – a Joint statement of Romanian civil society organizations[8] was sent to the Global Fund’s Executive Director and Fund’s Board in advance to its Thirty Sixth Meeting urging the Board to prevent zero allocation for the HIV component for Romania for the next three years. But their voice has not being heard and Romania was allocated zero funding for the 2017-2019 period.

The last attempt was done in May 2018 when more than 40 international, regional and national organizations addressed[9] the members of the Global Fund Board on the eligibility related issues in advance to its Thirty Ninth Meeting. In their statement, among other issues, civil society organizations called the Global Fund Board not to restrict access to funding for HIV for countries not on the OECD DAC List of ODA specifically appealing to the case of Romania. In the opinion of the subscribers of the statement, “by continuously preserving this requirement the Global Fund itself creates a political barrier that precludes the provision of evidence-informed interventions for key populations in these countries”.

Also, in the same statement the organizations called for the revision of the language of the “NGO Rule” on “political barriers” as this terminology has no clear definition, is inconsistent with international law and could be interpreted against the interests of key affected populations in countries.

Revised Policy – the same eligibility status

One of the result of this Global Fund’s Thirty Ninth Meeting was approval of the Revised Eligibility Policy. In the revised version of the document the OECD DAC ODA Requirement unfortunately was left as it was before but the term “political barriers” in the provision on the exception to the OECD DAC ODA Requirement for HIV/AIDS was replaced with just “barriers” with a note that eligibility for funding under this provision will be assessed by the Secretariat as part of the decision-making process for allocations. It further clarifies that as part of its assessment, the Secretariat will look specifically whether there are laws or policies which influence practices and seriously limit and/or restrict the provision of evidence-informed interventions for key populations.

It is not clear yet if this replacement of the term “political barriers” with just “barriers” will somehow influence the chances of Romania to receive an allocation for its HIV component within the next allocation period but probably not much. As before it will be the Global Fund Secretariat to decide if there are demonstrated barriers in country to providing funding for interventions for key populations, as supported by the country’s epidemiology. And it is clear from the clarification note that as before when considering the eligibility under this provision the Global Fund Secretariat will probably look not if representatives of key affected populations actually have access to the required for them HIV prevention services of a certain quality and at a needed scale but will still consider the existence of the laws and policies which restricts provision of such services by the government.

The only chance to Romanian HIV component to become ever eligible again – is the elimination of the OECD DAC ODA Requirement for HIV/AIDS in the Eligibility Policy. “By keeping the OECD DAC ODA Requirement for HIV/AIDS components the Global Fund continues to restrict access of Romanian NGOs to vitaly needed funding which could allow to ensure an appropriate HIV response among key affected populations“, – says Dragos Rosca, the Executive Director of the Romanian Harm Reduction Network.

At the same time in the opinion of Nicoleta Dascalu from the Romanian Association Against AIDS “it is not the Global Fund responsibility to support AIDS prevention services in Romania, and, if Romania becomes eligible again, the new project should include a strong advocacy component, that should pressure national responsible institutions and make them fund prevention.”

[1] Dente K, Hess J. Pediatric AIDS in Romania – A Country Faces Its Epidemic and Serves as a Model of Success. Medscape General Medicine. 2006;8(2):11.

[2] the HIV treatment/patient/year in Romania is around 6,000 euro ( p. 6)

[3] EMCDDA (2016). Statistical Bulletin. Table on HIV Prevalence accessed at:


[5] EU-funded project Sialon II. Report on a Bio-Behavioural Survey among MSM in 13 European Cities. Accessed at:

[6] Romania: Country Progress Report on AIDS Reporting period January 2015 – December 2015. Bucharest, April 2016. Available at:

[7] The Impact of Transition from Global Fund support to Governmental Funding on the Sustainability of Harm Reduction Programs. A Case Study from Romania. Eurasian Harm Reduction Network. 2016.

[8] Joint Statement from Romanian civil society urging Global Fund to maintain funding

[9] Joint Statement of Civil Society Organizations in advance of the Thirty-Ninth Meeting of the Global Fund Board

This text is the author’s version of the article published at

The sustainability of the results of the last Global Fund HIV grant for Russia are under a threat

Abstract: The results of the implementation of the recently closed HIV program in Russsia are under a threat due to the ineligibility of country for Global Fund‘s transition funding and unwillingness of the government to suppot the implemented activities. At the same time there is a chance that Ruissa could become eligible for GF HIV funding again starting from the next year and receive an allocation for the next 2020 – 2022 period.


The sustainability of the results of the last Global Fund HIV grant for Russia are under a threat

Although Russia could become eligible again for the Global Fund HIV funding and even receive allocation within the next allocation period

Conflict of interest: the author of the article is a member of the Coordinating Committee which was responsible for coordination and oversight of the implementation of the Global Fund HIV grant in Russia being discussed in this article.


By the end of implementation of its round-based model of grants’ distribution the Global Fund has invested more than 250 million USD within the Round 3, Round 4 and Round 5 HIV and TB grants to ensure the sustainable response to HIV and TB epidemics in Russia.

A 2010 study by Russian Federal AIDS Center estimated that less than 1% of key populations had access to HIV prevention programs in Russia. The majority of programs providing HIV prevention services to key populations in Russia were dependent on foreign funding. By 2014, the implementation of HIV programs financed by the Global Fund, including those targeted on key populations came to an end. The Russian government didn’t take any steps to fund or even acknowledge the need for HIV programming for key marginalized and criminalized populations, PWUD, SW and MSM/LGBT despite all those promises given by the Minister of Health in 2008 to step in and start paying for such services once the GF programs ended[1].

In light of this situation, the Global Fund has approved the 12 million USD HIV Program in Russia for the period 2015-2017 which was supported within the so called “NGO-Rule” – a provision within the Global Fund’s Eligibility Policy which allows for potential eligibility for UMICs that meet the disease burden thresholds for HIV but are not on the OECD DAC List of ODA Recipients. Local NGO Open Health Institute (OHI) was selected as the Principal Recipient (PR) to continue the activities initiated under two recent HIV programs supported by the Global Fund in Russia and to “create [an] environment for integration of…evidence-based programs into the national HIV strategy”, and to “strengthen the communities of Key Populations in order to increase their involvement in the dialogue with the authorities”[2].

Program details and its uniqueness

This program consisted of three intertwined components: HIV service delivery for PWID, SW and MSM, community systems strengthening (CSS), and removing legal barriers (RLB). From 2015 the activities included services for 17 PWID programs, 5 MSM, and 5 SW. Additionally, in both 2016 and 2017, 12 programs were co-financed and 20 more were given small grants for overcoming legal barriers and rights defense. By the end of its implementation the grant had shown very good results against the targets set (102% average performance of all indicators) and was rated B1, with eight out of ten of its indicators rated A1[3]. A 17 July 2017 Global Fund management letter[4] especially commended “increased mobilization of key affected populations…through the Community Systems Strengthening module,” and praised the Removing Legal Barriers Module for “[showing] excellent results and… contribut[ing] to increasing literacy of key affected populations to help them access health services or navigate through a punitive legal environment”.

The uniqueness of this project is that it was developed and implemented by the forces of the NGOs and communities’ representatives only, without any involvement and support from the governmental sector. The Coordinating Committee (analogue to CCM but without involvement of the governmental sector) was established by the civil society based National Dialogue to coordinate the implementation of the project. “The Coordinating Committee brought together key populations groups, groups of people living with HIV, NGO representatives and human rights advocates who had previously not found common ground, enabling them to forge a common platform and agenda”, says Victoria Dollen, Secretary of the Coordinating Committee.

Also, within the implementation of this project each key population group created sustainable key populations monitoring mechanisms (key populations Forums) to ensure key populations engagement into the meaningful dialogue with the government at all levels.

Reminding about the HIV situation in Russia and its impact on the EECA Region

The region of Eastern Europe and Central Asia (EECA) is the only region in the world where the HIV epidemic continues to grow[5], and Russia could be considered as a „driving force” of the epidemic in the region. According to UNAIDS 2018 Global AIDS Update “the HIV epidemic in Eastern Europe and central Asia has grown by 30% since 2010, reflecting insufficient political commitment and domestic investment in national AIDS responses across much of the region. Regional trends depend a great deal on progress in the Russian Federation, which is home to 70% of people living with HIV in the region. Outside of the Russian Federation, the rate of new HIV infections is stable. Insufficient access to sterile injecting equipment and the unavailability of opioid substitution therapy are stymying efforts in the Russian Federation to prevent HIV infections among people who inject drugs”.[6]

For several years now, there has been a concentrated HIV epidemic in Russia among such key groups affected by HIV as injecting drug users, men who have sex with men and sex workers[7], and in some regions of the country a generalized epidemic among the general population is even being observed[8]. About 70% of all HIV cases in Russia are associated with the use of injecting drugs and still the main way of HIV transmission is parenteral. Recent IBBS research conducted in seven cities of Russia within the implementation of the “NGO rule” HIV Program demonstrates 48,1 – 75,2% HIV prevalence among people who inject drugs (PWID), 7,1 – 22,8% among men who have sex with men (MSM), and 2,3-15.0% among sex workers (SW).[9] With more then 1 220 000 cases being registered as on the end of 2017, the coverage by HIV treatment of PLH in country is about 35%[10].

Given these facts, as well as taking into consideration the geopolitical position of the Russian Federation, the migration flows in the region, etc., it is clear that when planning a response to HIV epidemic in EECA region it is impossible to neglect an HIV situation in Russia and not to support HIV response in this country, as such approach can ultimately reduce to zero all efforts by donors and governments to counteract the HIV epidemic in neighboring countries.

Russia’s eligibility and perspective for sustainability of HIV services

The implementation of this last Global Fund’s HIV grant in Russia has ended on December 31st 2017 with a closure period to end on September 30th 2018. During the Thirty-Ninth Meeting of the Global Fund Board which took place in May 2018 a decision was made to preserve the OECD DAC ODA Requirement for HIV/AIDS in the Global Fund’s Eligibility Policy as well as the exception to OECD-DAC ODA Requirement for funding civil society for HIV/AIDS (formerly referred to as the “NGO Rule”). This means that there is a chance that Russia, as the only country in the world yet which has proved itself eligible for Global Fund’s HIV funding within the “NGO rule”, could be considered eligible under this provision again and may receive an allocation within the next allocation period 2020 – 2022.

Unfortunately, Russia was not eligible to receive any transition funding from the Global Fund to sustain the achievements of this HIV project and now there is a risk that most of the services on HIV prevention that are being carried out by the NGOs within this program, as well as initiatives aimed at advocacy and protection of the rights of representatives of communities, may cease their work in the nearest future, because the funding allocated by the state is not enough to support them, or such funding is not allocated at all.

In addition to inability to receive the transition funding country has lost about 650 000 USD[11] due to the internal regulations of the Global Fund Secretariat according to which all currency translation difference could not be spent on the program activities but should be returned to the Global Fund. This money also could be used to allow the continuation of the key project activities till the beginning of the new allocation period. At the same time the Coordinating Committee has a funding from the Global Fund to till 31.01.2020.

Urgent actions to ensure the sustainability of the project results are needed

The Russian Coordinating Committee is making now the attempts to attract the attention of the Global Fund’s Secretariat and Delegations to the Global Fund to this situation with threat to the sustainability of the results of the recent HIV project by calling to ensure the continuation of HIV prevention services and community-based response in Russia at least until the new allocations for 2020 – 2022 to be announced by the Global Fund Secretariat. There is no any sense to abandon after every three years everything which was achieved with the support of the Global Fund’s funding and then start everything from scratch – this is just a waste of money, time, efforts and lives of people affected by HIV.

“This NGO-Rule Program demonstrated that key affected populations can and in fact should design, implement, and control WHO recommended HIV prevention services among key populations. The Program is a success story and a best practice in creating key populations mechanisms for monitoring of service quality and human rights violations, and to engage key affected populations into the meaningful dialogue with the government”, says Mikhail Golichenko, Senior Policy Analyst from the Canadian HIV\AIDS Legal Network. “This Program was inexpensive tool to contribute to communities’ systems strengthening, support them to overcome the legal barriers and retain KAPs as equal parties in the dialogue with the Russian Government, and as such should not be lost due to the lack of funding”.

[1] S. Shonning. Community Systems Strengthening and Removing the Legal Barriers Modules of the Global Fund Program: Improving access to prevention, treatment and care for key population groups in Russia: Baseline and progress to date Report. January 2017 (on file with the author).

[2] The Global Fund, Charitable Donation Agreement, RUS-H-OHI (on file with the author)

[3] The Global Fund, RUS-H-OHI-RP: 3-SI-762018. Performance Letter Progress Report covering the period 1 January, 2017-31 December, 2017 (on file with the author).

[4] On file with the author


[6] UNAIDS 2018 Global AIDS Update. 2018. Online:



[9] Federal AIDS Center or Rospotrebnadzor. Information Note. HIV in Russia in 2017. Online:

[10] Ibid

[11] Presentation by E. Kryanina, ED of OHI (PR of the GF HIV grant) at the meeting of the Coordinating Committee on 07.06.2018. (on file with the author).

This text is the author’s version of the article published at

Global Fund grant to Ukraine finds treatment success for multidrug-resistant TB with two-pronged approach

Author: Ivan Varentsov, EHRA Sustainability and Transition Advisor and Coordinator of the EECA Regional Platform for Communication and Coordination

According to the WHO, Ukraine remains a country with a high TB burden, and in 2014 it became one of the five countries with the highest burdens of multidrug-resistant tuberculosis (MDR TB) in the world. The TB epidemic in Ukraine is marked by the spread of multidrug-resistant and extensively drug-resistant tuberculosis (XDR TB), relatively high MDR TB mortality and one of the lowest TB treatment success rates in the region of Eastern Europe and Central Asia – 72% in new TB cases and 38,6% in patients with MDR TB (WHO, 2016).

Currently the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) is supporting the implementation of programs to fight tuberculosis in Ukraine within a new country HIV/TB grant for 2018-2020, as well as through catalytic funding. The current program, which started this year, is being based on the previous three-year project, “Investing for Impact against Tuberculosis and HIV”, which had been implemented in Ukraine in 2015-2017 and was completed, with success, at the end of last year.

One of the three key implementers of this project was the Alliance for Public Health (the Alliance), which was responsible for a number of program components, in particular for providing medical and social support to ensure adherence to MDR-TB treatment. Implementation of this latter component achieved high success rates (up to 80%).

Key success factors and outcomes

One of the key factors contributing to the success of this project component was the use of the DOTS approach (Directly Observed Treatment Short-course) in combination with social support for patients, which included the delivery of psychosocial services and training in treatment adherence. This project was implemented in all regions of the Ukraine and performed strongly in all of them.

Apart from the Alliance, other partners involved in implementation included the Public Health Center of the Ministry of Health of Ukraine and the Ukrainian Red Cross Society. The Red Cross Society, which has a wide network of branches covering all the regions of Ukraine, and also has the required number of visiting nurses, was responsible for the DOTS and social support components of the project.

Before patients were released from hospitals, they were asked if they would like to be involved in the project at the outpatient stage of treatment. If the person agreed, information about the patient was given to a relevant branch of the Red Cross Society, where a supervisor was assigned to receive that patient’s TB drugs, attending to the patient daily. If the patient did not miss any doses, he would receive food parcels twice a month.

The efforts of the Alliance and its partners to provide medical and social support to patients and establish their adherence to MDR TB treatment within this project continued the work that had been started in 2013 with the implementation of the previous Global Fund TB grant from Round 9. In 2013, just over 100 patients were enrolled in the support program. Treatment success rates were very high, at 86%, while the treatment success rate for patients with similar conditions who also received treatment within the Global Fund project but were not covered with DOTS or by social support from the Red Cross, was 44% (according to the Alliance).

According to one staff member from the Alliance, one of the reasons for such high treatment success rates was the approach the program used to select patients: at first patients for whom good treatment outcomes were expected were enrolled in the program – ‘treatment-naïve’ patients, patients with repeated TB cases (if the previous TB case was cured) and patients whose first treatment courses had failed. Further, starting from 2014, all patients eligible for the treatment regimens procured within the Global Fund project were enrolled in treatment. After 2015, the patients who received treatment within the state budget were also enrolled in the program.

In 2014, the treatment success rate for the 500 patients covered by the project was 79%, and in 2015 it was 75%. The target for patient coverage in the three years from 2015 to 2017 was 9,300 patients, and was overachieved – the actual number of patients with MDR TB covered by the program was 9,420. (Treatment success rates for the patients enrolled in 2016 will be available later in 2018.

According to Eugenia Geliukh, the program’s project manager, the program can be credited with improving the overall MDR-TB treatment success rates in the country: In 2012 it was 34%, in 2013 it was 39%, and in 2014, 46% (WHO Tuberculosis country profile).

Ensuring sustainability of the TB response in Ukraine

“In three years, we fully piloted the DOTS model combined with social support of the patients and proved the efficiency of this project in Ukraine,” says Andrey Klepikov, Executive Director of the Alliance for Public Health. “Our main message to the government is to make sure that, considering the existing evidence base and taking into account the ongoing processes of transition of TB programs from Global Fund support to domestic funding, this component will also be taken over by the state.” Klepikov suggested that treatment success rates would be halved if, after the withdrawal of Global Fund support, the government supported only drug procurement, without the social support component.

This aspect is crucial as in recent years there has been a rapid transition of the TB response to domestic funding. Until 2017, procurement of half of the second-line drugs to treat multidrug-resistant forms of TB in the country was covered by the Global Fund; starting in 2018, the government took over the procurement of all TB and MDR-TB drugs. Moreover, it is planned that by the end of 2018, 90% of XDR-TB treatment will be covered by domestic funds. The remaining 10% will be procured by the Alliance within Global Fund programming (133 schemes with delamanid).

So far, the equipment for rapid TB diagnostics, supplies and reagents are mainly procured with financial support from the Global Fund and other donors. According to the new Global Fund grant agreement, to implement the 2018-2020 HIV/TB project, every year the procurement of equipment will incrementally be covered from the state budget. Currently, a National TB Program concept has been approved in Ukraine, and it is expected that this year the Parliament will approve the National TB Program for 2018–2021.

Within the new grant, in 2018, support for patients who receive treatment will remain the responsibility of Alliance, in eight regions of the country, with no Red Cross Society involvement. However, it is planned that the social component will also gradually be taken over by the government. In 2018, it is projected that social support for 20% of patients receiving support from NGOs will shift to the Ministry of Ukraine’s Public Health Center. Financial support for this activity will still come from the Global Fund, and the Alliance provides technical support to the PHC within this component.  Starting from 2019, 50% of patients will receive support from within the state budget and in 2020, it is expected that 80% of the patients will receive support from the state.

TB treatment approach based on results-based financing model

The Alliance also has implemented a pilot MDR-TB treatment project using a results-based financing (RBF) model. In 2017, the Alliance applied this approach when implementing opioid substitution treatment programs in the Odessa region, within the same Global Fund grant, and decided to adapt it to TB treatment based on the DOTS model. The main goal of the project was to reduce treatment costs per patient per year, and to hand over the implementation of DOTS and social support for TB patients to the primary-care level of the state healthcare system.

“Involvement of the Red Cross Society or other NGOs in DOTS implementation is an interim solution,” says Eugenia Geliukh. “Such projects can be implemented only as long as donors support them. As soon as donors stop financing those activities, NGOs will not be able to continue them at their own expense. At the same time, delivery of treatment services through primary healthcare centres (PHCCs) is in line with the concept of the healthcare reform which is currently going on in Ukraine.”

Within the project, Alliance signed contracts with 14 PHCCs in the Odessa region to implement DOTS and provide social support to patients receiving treatment. The specific mode of providing DOTS services was defined by each PHCC.

Within the pilot project using the RBF model the cost of treating one MDR TB patient for one year was UAH 9,000 (compared to UAH 13,000 for the Alliance project) with the same outcomes. Treatment success rates for the MDR TB patients are not yet available as they have not yet completed their treatment. But for the patients with drug-susceptible TB, the average treatment success rate was 93%, compared to the 35–40% registered in some Odessa region districts before the pilot project implementation started.

This project was not included in the new program supported by the Global Fund for 2018–2020. Moreover, within the new programme the government made a decision to go back to DOTS provision by NGOs and not by state-run primary healthcare institutions. But the city of Odessa became interested in the pilot project’s results. The annual budget of UAH 2,2 million (which is equivalent to $85,000) is allocated within the Odessa city HIV/TB program for 2019–2020, to cover up to 700 people with DOTS through primary healthcare centres. In 2019 half of these funds are expected to be covered by the city budget, and in 2020, 100%.

“In the end, the results-based financing model has been accepted and supported with municipal funding,” said Andrey Klepikov, executive director of the Alliance for Public Health. “It is a great victory for ensuring sustainability and transition. And civil society will remain one of the key players in our national TB response, becoming more and more recognized by the Ukrainian government.”

Source of the original content:

TBEC case study on the impact of Global Fund transition on the region (procurement in Georgia)

Georgia has a low HIV prevalence and decreasing incidence rates of tuberculosis (TB), indicative of strong leadership and collaboration between partners to fight the two diseases. However, there remains an increasing number of HIV cases in key populations, including people who inject drugs and men who have sex with men, treatment outcomes remain unfavorable for people with TB and there are high rates of drug-resistant TB, for which treatment outcomes are poor.

Global Fund has provided financial assistance to Georgia’s national HIV/AIDS Programme since 2003 and the National TB Programme since 2005. Global Fund plays a crucial role in ensuring access to treatment, including allowing Georgia to procure quality assured, affordable drugs through pooled procurement mechanisms, such as Global Fund’s Pooled Procurement Mechanism for HIV and the Global Drug Facility (GDF) for TB. Georgia was recently re-classified as a lower-middle income country (LMIC) by the World Bank, despite GDP per capita gradually increasing in recent years, and this could impact its co-financing requirements with Global Fund after the current 3-year funding cycle ends.

This case study explores how Georgia and the Global Fund have acted to ensure that transition from Global Fund funding does not compromise stable procurement of TB and HIV commodities and access to medicines, in terms of both continuity and scale up. Georgia has been successful through early planning, collaboration with partners and many other reasons explored throughout this case study.

Please find the full version of the case study here.

Joint Statement of Civil Society Organizations in advance of the Thirty-Ninth Meeting of the Global Fund Board

On May 9–10 2018, the Global Fund’s Board will consider revisions to the Fund’s Eligibility Policy based upon recommendations from its Strategy Committee. While some of these recommendations are positive, others raise serious concerns.

In this regard organizations representing civil society and including communities of people living with and affected by the three diseases and other key populations from different countries and regions – developed a Joint Statement to share with Global Fund Board members their position on several critical issues that should be considered by the Board during its deliberations on the Eligibility Policy.

The Statement signed by 41 international, regional and national level organizations was sent to the focal points of all Delegations to the GF Board as well as to GF Board Leadership and GF ED. 7 more organizations signed the statement after it was sent.

We hope that our position will be taken into account by the Global Fund Board members when making decisions on the eligibility issues during the Board meeting.

The final version of the document – Joint Statement of Civil Society Organizations in advance of the Thirty-Ninth Meeting of the Global Fund Board.

Status of transitions from Global Fund support in the EECA region

Author: Ivan Varentsov, EHRA Sustainability and Transition Advisor and Coordinator of the EECA Regional Platform for Communication and Coordination

Eastern Europe and Central Asia (EECA) is one of two regions, along with Latin America and the Caribbean, where planning for the transition away from Global Fund support is most advanced. In this article, we provide an overview of the transition status of HIV, TB and malaria components of the countries in the EECA.

The STC Policy

In April 2016, the Global Fund’s Board adopted a Sustainability, Transition and Co-Financing (STC) Policy, which outlines (a) the high-level principles for engaging with countries on the long-term sustainability of Global Fund–supported programs, as well as (b) a framework for ensuring successful transitions from Global Fund financing.

According to the STC Policy, all countries, regardless of their economic capacity and disease burden, should be planning for sustainability and embedding sustainability considerations within national strategies, and program and grant design and implementation. For countries with high disease burdens and fewer resources, the STC Policy emphasizes the need for domestic investments to build resilient and sustainable systems for health and move towards universal health coverage. As countries move along the development continuum –– either by increasing economic resources or lowering disease burden –– expectations are for greater transition planning, as well as for co-financing targeting specific transition challenges and programming for key populations.

The Global Fund’s Eligibility Policy allows components that become ineligible from one allocation period to the next to receive one allocation of transition funding “for priority transition needs.” This applies to most country components with existing grants, but there are exceptions. Components are not eligible for transition funding if the country:

  • becomes categorized as high-income; or
  • is a member of the G-20, moves to upper-middle-income (UMI) status and has less than an extreme disease burden; or
  • becomes a member of the Organization for Economic Cooperation and Development’s (OECD) Development Assistance Committee (DAC).

For components eligible for transition funding, the STC Policy states that the funding request should focus exclusively on activities that are included in the country’s transition work plan and that are essential to achieving, by the end of the grant, full domestic funding and management of activities currently funded by the Global Fund.

The clause concerning transition funded was added to the Fund’s eligibility policy in November 2013. (The policy was called the Eligibility and Counterpart Financing Policy at the time.)

For the purposes of this overview, we have divided components into the following categories:

  • components that did not receive transition funding because they were already ineligible when the policy on transition funding was adopted;
  • components receiving transition funding for the 2017–2019 allocation period;
  • other components that are projected to transition away from Global Fund support by 2025;
  • other components that have started transition planning; and
  • components that still have time for long-term transition planning.

Components that did not receive transition funding because they were already ineligible when the policy on transition funding was adopted

A number of components are included in this category. Below, we list those that were active as recently as 2015.

Bulgaria HIV. The last HIV grant was a rounds-based grant that was originally planned to end on 31 December 2015. In order to support the country with HIV prevention activities for key populations, the grant was extended and then went through a closure period that ended in September 2017. In both 2016 and 2017, as per the Global Fund’s eligibility list, Bulgaria HIV was potentially eligible for funding under the NGO Rule. However, Bulgaria did not meet the political barriers requirement of the rule.

Bosnia and Herzegovina HIV. The last rounds-based HIV grant ended on 30 September 2016, after which it went through a grant closure period. The closure period continued into 2017. At the end of 2017, the Global Fund Secretariat, using flexibilities under the STC Policy, exceptionally approved to continue the grant closure period through 31 November 2018. This will allow the continuation of a limited number of activities to facilitate the transition of prevention and care and support services for key populations in Bosnia and Herzegovina.

Bosnia and Herzegovina TB. The end date for the last TB grant was 31 July 2016.

Macedonia HIV. The last rounds-based HIV grant came to an end in December 2017. This was after a 12-month non-costed extension of the grant was made using flexibilities under the STC Policy to help ensure a responsible transition of HIV activities, and to support ongoing efforts at the country level to advocate for increased domestic resources for key and vulnerable populations.

Macedonia TB. The last TB grant formally ended in September 2016. There was a non-costed grant extension to 31 March 2017 to support the country to transition from Global Fund support.

(Both Macedonia and Bosnia and Herzegovina were ineligible for Global Fund support as early as 2010 because they were categorized as upper-middle-income (UMI) countries and had less than a high disease burden for both HIV and TB. Both countries benefited from a previous policy provision which allowed them to still be considered as lower-middle-income (LMI) countries.

Russian Federation HIV. The last HIV grant ended in December 2017, with a closure period expected to end in June 2018. This was a non-CCM grant under the NGO Rule.

Serbia TB. The last rounds-based TB grants ended on 31 March and 30 June 2015.

Components receiving transition funding in 2017–2019

The following components became ineligible for regular funding after the 2014–2016 allocations were announced and were therefore eligible to receive transition funding for 2017–2019:

Albania HIV. This component became ineligible for regular funding in 2015 and was subsequently allocated $1.1 million in transition funding for 2017–2019.

Albania TB. This component became ineligible for regular funding in 2015 and was subsequently allocated $500,000 in transition funding for 2017–2019.

Turkmenistan TB. This component became ineligible for regular funding in 2016 and was subsequently allocated $4.0 million in transition funding for 2017–2019.

Note: Bulgaria has an existing TB grant from the 2014–2016 allocation period which is scheduled to end in September 2018. The TB component became ineligible for further regular funding in 2016. Bulgaria TB should have been eligible to receive transition funding for 2017–2019. However, Aidspan was told by the Global Fund Secretariat that in June 2015 the existing TB grant was developed and negotiated with the understanding that Bulgaria would not receive further funding from the Global Fund, and that the necessary measures for a successful transition to domestic funding would be adopted during implementation of the existing grant (see GFO article).

Other components projected to transition by 2025

To support countries in their planning, the Global Fund produced a list of components projected to transition fully from Global Fund financing by 2025 due to changes in income categorization and/or disease burden classification. (The list assumes current eligibility criteria will continue to apply.) The following EECA components are on this list:

The Kosovo territory HIV and TB. Both components are projected to become ineligible in 2020–2022 based the country’s anticipated move to upper-middle-income status and may receive transition funding in 2023–2025.

Kazakhstan HIV and TB. The country is projected to move to the high-income category during 2023–2025. Both components will not be entitled to receive transition funding because high-income countries are ineligible across the board.

Armenia HIV and TB. According to the recently published Eligibility List 2018, Armenia is newly categorized as a UMI country. As a result, both components are now eligible to receive a final allocation of transition funding in 2020-2022. (See GFO article on the new eligibility list.)

Other components that have started transition planning

The Global Fund expects all eligible UMI countries –– and all eligible LMI countries with components whose disease burden is classified as low or moderate –– to begin sustainability and transition planning, or to build upon existing planning, during the 2017–2019 period. There are six countries in the EECA with components that are in this cohort and that are not already on the list of components projected to transition by 2025: Azerbaijan (HIV, TB), Belarus (HIV, TB), Georgia (HIV, TB), Montenegro (HIV), Serbia (HIV) and Romania (TB). These countries are already working on transition. For example, both Belarus and Georgia have already developed formal transition plans and have started to implement them (for Belarus, see GFO article).

There are no active Global Fund malaria grants in the EECA region.

Components that still have time for long-term sustainability and transition planning

While it is not possible to predict with certainty transition timelines, components from low-income countries (regardless of disease burden) and components from LMI countries with a disease burden classification of high or above are not expected to transition from the Global Fund support imminently. But under the STC Policy, they are expected to focus on long-term sustainability planning by supporting the development of robust national health strategies, disease-specific strategic plans and health financing strategies.

There are no low-income countries in EECA region. However, components from the following LMI countries fall under this category: Kyrgyzstan (HIV, TB), Moldova (HIV, TB), Tajikistan (HIV, TB), Uzbekistan (HIV, TB), Ukraine (HIV, TB).

Summary table

The following table provides a list of the components in the various categories discussed above.

Table: Components in the various categories of transition from Global Fund support

Ineligible before the policy on transition funding was adopted *Receiving transition funding in 2017–2019Projected to transition by 2025Started transition planningStill have time for long-term sustainability and transition planning
Bulgaria HIV
Macedonia HIV
Russia HIV
Serbia TB
Albania HIV, TB
Turkmenistan TB
Armenia HIV, TB
the Kosovo territory HIV, TB
Kazakhstan HIV, TB
Azerbaijan HIV, TB
Belarus HIV, TB
Georgia HIV, TB Montenegro HIV
Serbia HIV
Kyrgyzstan HIV, TB
Moldova HIV, TB
Tajikistan HIV, TB
Uzbekistan HIV, TB
Ukraine HIV, TB

* In the first column, only components still active as recently as 2015 are listed.

Transition in reverse: Components that regained their eligibility

There are three countries in EECA region whose HIV components were newly classified as eligible on the Eligibility List 2017 after meeting eligibility criteria for two consecutive eligibility determinations, and which received allocations for the 2017–2019 period. These components are as follows:

Kazakhstan HIV. This component became ineligible for Global Fund support in 2011 because it was a UMI country with only a moderate disease burden. However, its HIV disease burden classification changed to high on the Eligibility List 2016.

Montenegro HIV.  Montenegro became ineligible for both HIV and TB in 2008 when it moved up to UMI status and its HIV and TB components had less than a high disease burden. Both components “hung on” until Round 9 in 2009 because they benefited from a previous policy provision (which is no longer exists) which allowed them to “keep” their LMI status for an extra year. In 2016, Montenegro’s HIV disease burden classification was changed to “high.”

Serbia HIV. As a UMI country, Serbia’s funding ended abruptly after its HIV burden was lowered to moderate. Its HIV burden classification went back up to high in 2015.

Both Montenegro and Serbia were told, via their allocation letters, that their allocations for 2017–2019 were conditional on their funding requests focusing on key affected populations. Specifically, the letters stated that the allocations “are dependent on the functionality, in form and substance acceptable to the Global Fund, of a social contracting mechanism for engagement of non-governmental organizations through which the … governmental institution(s) and the Global Fund will finance HIV prevention, care and support activities.”

Source of the original content:

Lost in Transition: Three Case Studies of Global Fund Withdrawal in South Eastern Europe

Working paper, Open Society Foundations Public Health Program, November 2017

This brief provides three case studies of the transition to domestic financing of HIV response in South Eastern Europe after the withdrawal of the Global Fund to Fight AIDS, Tuberculosis and Malaria. These case studies—of Macedonia, Montenegro, and Serbia—are intended as a resource for funders, advocates, and policymakers interested in supporting civil society-led efforts and partnerships with government to ensure the sustainability of services during and after transition.

As funding from the Global Fund is phased out, Bulgaria struggles to find sustainable financing

With Global Fund support coming to an end, the path towards sustainability of HIV and TB services for key affected populations (KAPs) in Bulgaria is not clear. The consensus among representatives of civil society organizations is that, unfortunately, Bulgaria still has not managed to ensure within its National Strategic Plan for HIV sustainable financing at the required level for the services provided by NGOs for prevention, treatment and reduction of HIV among KAPs. At the same time, NGO advocacy remains weak, and many activists see little recognition by government and local authorities of the NGO role in the response to HIV and TB.
 Author: Ivan Varentsov

With Global Fund support coming to an end, the path towards sustainability of HIV and TB services for key affected populations (KAPs) in Bulgaria is not clear. The consensus among representatives of civil society organizations is that, unfortunately, Bulgaria still has not managed to ensure within its National Strategic Plan for HIV sustainable financing at the required level for the services provided by NGOs for prevention, treatment and reduction of HIV among KAPs. At the same time, NGO advocacy remains weak, and many activists see little recognition by government and local authorities of the NGO role in the response to HIV and TB.

“The lack of a vibrant and meaningful civil society is being felt very strongly right now,” Yuliya Georgieva, from NGO Center for Humane Policy, told Aidspan. “At a time when the Global Fund is finally ending its lengthy presence in the country, it has become clear that there is a complete lack of the civil society energy that is needed to advocate for the necessary funds and mechanisms for an effective continuation of the program.”

Bulgaria is a member of the European Union and is classified by the World Bank as an upper-middle-income country. Bulgaria has not been eligible for funding for HIV since 2015; it received no HIV funding for the current allocation period (2017-2019). The latest HIV grant, which was extended a number of times, ends this month.

Bulgaria’s current TB grant will come to an end in September 2018. Technically, the TB component should be eligible for a transition grant after that. However, earlier this year, the Global Fund Secretariat told Aidspan that the existing grant to the Ministry of Health (MOH) was developed and negotiated with the understanding that Bulgaria would not receive further funding from the Global Fund, and that the necessary measures for a successful transition to domestic funding would be adopted during implementation of the existing grant (see GFO article).

Epidemiological situation and the national response

Bulgaria remains one of the E.U. countries with the lowest HIV incidence: it registers 3.1 new cases per 100,000, or 200-220 new cases annually. According to research conducted by Optima involving modelling HIV epidemics for the next five years, two groups will account for most of the new HIV cases: people who inject drugs (PWIDs) and men who have sex with men (MSM). In the last six years, the proportion of new HIV cases attributed to injection drug use declined by two-thirds; however, it doubled for MSM, who have accounted for 50% of new cases in the last three years. A network of various services for reaching key populations with HIV prevention has been developed: 14 testing and counseling sites; mobile units; outreach work; and drop-in centers.

With respect to TB, the incidence rate more than halved from 48.8 per 100,000 population in 2001 to 21.3 in 2016. But the rate still remains among the highest in the E.U. Treatment success increased from 81% in 2007 to 86% in 2016, and few drug-resistant cases are present (unlike in most of Eastern Europe and Central Asia). NGOs provide TB services across the country among the following groups: inmates (13 prisons); Roma communities (23 sites); children at risk (nine sites); refugees and those seeking refugee status and other migrants (three services); and other groups, such as people who use drugs, and the homeless (11 sites).

Key national documents to ensure sustainable public funding for HIV and TB responses were approved of by the Cabinet of Ministers in March 2017, covering the period 2017-2020. The adoption of these important documents was delayed for several months, due to the rather low priority given to these diseases by the Bulgarian government, and also due to political instability and frequent government changes throughout 2016. The national programs described in these documents contain indicative budgets for the services implemented by NGOs, including for HIV prevention. There are specific budget lines for each key and vulnerable population group for each of 2017, 2018, 2019 and 2020 (see the table for the numbers for 2017 and 2018).

Table: National Program budget for HIV for 2017 and 2018 (BGN)

281,610 BGN
200,000 BGN
212,534 BGN
160,000 BGN
156,895 BGN
170,000 BGN
Marginalized ethnic communities (Roma)
105,000 BGN
210,000 BGN
People in prisons
25,000 BGN
50,000 BGN
Refugees, migrants and mobile populations
50,000 BGN
100,000 BGN
Children and young people
55,000 BGN
110,000 BGN
Total for key populations
886,039 BGN
1,000,000 BGN
Total for HIV program
2,808,161 BGN
2,973,309 BGN

As a comparison, NGOs working with key population groups in 2015 effectively spent € 907,588 under the Global Fund grant. There are about two BGN to the euro. It is clear, therefore, that the money planned within the National Program for the most-at-risk groups is less than half of what was previously provided by the Global Fund This will likely have a major impact on the sustainability of the HIV services currently implemented by NGOs. Note, also, as shown in the table, that the sum of money for the PWID and MSM decreases in the second year (2018). The budget for these populations is maintained at this lower level for 2019 and 2020.

Further, as Dr. Georgi Vasilev, one of the authors of a recently published analytical report on contracting public healthcare and social services to CSOs in Bulgaria, told Aidspan: The problem is that these figures show the projected budget; the money actually made available is likely to be less.

Around 600,000 BGN is budgeted are planned annually for TB prevention in 2019 and 2020, the first years without the Global Fund support for the TB response. In comparison, the budget for the TB care and prevention module within the current Global Fund TB grant stands at € 1,504,841 for 2016 and € 1,288,286 for 2017.

Role of NGOs in HIV and TB response

Bulgarian NGOs have been significantly involved in the implementation of the program financed by the Global Fund for the prevention and control of HIV in Bulgaria ever since the program started in 2004. More than 50 NGOs were involved in providing HIV prevention services to KAPs, with 10 NGOs working with PWID; nine NGOs working with sex workers; five NGOs working with MSM; 10 NGOs working with Roma youth; and four NGOs providing support to PLHIV. In addition, 17 mobile units and a number of low threshold centers operating with different risk groups were established and run by different NGOs.

With support from the Global Fund winding down, the key challenges faced by the NGOs and other community groups concern (a) funding; (b) their ability to continue delivering services at the same scale; and (c) how to utilize the capacity built up throughout past years. A few NGOs have already stopped providing HIV and TB services, though many NGOs have managed to survive funding interruptions because of their commitment to the issues.

The major problem with regard to ensuring the sustainability of NGO services to KAPs is the lack of a proper mechanism to allow NGOs to receive governmental funding. According to a recent analysis of this issue conducted by the Eurasian Harm Reduction Network, the existing mechanism for the implementation of NGO contracting was developed only for the purposes of the Global Fund grant. The State Procurement Agency has indicated that the mechanism adopted for the grant cannot be applied to state funding for NGOs. Instead, the Agency said, NGOs need to be contracted according to the provisions of the State Procurement Law. The MOH is still in the process of developing a new procedure for NGO contracting under the NSP. This will result in an interruption in funding for NGOs, and will affect the delivery of services to KAPs. As an interim measure, until the state procurement procedure for NGO contracting is operational, the MOH has instructed regional health inspectorates to hire outreach workers from NGOs previously delivering services, in order to maintain the outreach work into vulnerable communities.

Civil society advocacy

As it seems apparent that the national government has limited financial resources and thus might not fully replace the Global Fund’s support for HIV and TB services in the country, this could be the right time for sustainability- and transition-focused national level advocacy activities to take place in Bulgaria.

At the beginning of July 2017, a three-day civil society workshop took place in Sofia organized by the Eurasian Harm Reduction Network (EHRN) and the TB Europe Coalition (TBEC) with the support of the Global Fund Secretariat. The workshop brought together 23 local participants representing NGOs and affected communities, as well as governmental structures (such as the MOH), the CCM Secretariat and the National Municipalities Association. As a result of the workshop, the following key sustainability- and transition-related activities for this year were identified by the NGO participants:

  • initiate the revision of the national legislation which regulates the contracting procedure to ensure that NGOs are able to receive the governmental funding for HIV and TB prevention services among key affected populations in Bulgaria;
  • support the national budget allocation processes for 2018 to ensure that the required amount of funds for HIV and TB treatment and prevention programs are included and approved in the national budget;
  • explore possibilities of national funding of services for key affected populations in other national programs, such as the National Strategy Against Drugs; and
  • create an informal coalition of community organizations and NGOs for the purpose of coordinating and implementing joint advocacy work.
 According to the report of this workshop, in order to achieve the desired results, Bulgarian civil society has to gather support for their advocacy activities from both internal and external partners. This is particularly sensitive as most of E.U. member countries are normally not eligible for any donor support or development assistance other than that provided by the E.U. itself.

According to Sandra Irbe, Senior Fund Portfolio Manager for the Global Fund, civil society and community representatives could rely on the support of the Global Fund Secretariat for their sustainability-focused advocacy activities. For example, before the end of the current TB grant, NGOs could utilize the remaining support from the Global Fund – such as the CCM Secretariat funding of € 30,000 to finance advocacy meetings, consultations and oversight visits. The Global Fund’s political leverage with country stakeholders could also be exploited, Irbe said. “The Global Fund can also bring NGOs together with regional partners in other countries to learn and discuss transition and sustainability.”

Also, as the current grant for TB runs until September 2018, Irbe said that it is important to fully absorb the funding available with this grant. Some activities that are key for the national TB program might also provide entry points for KAPs to HIV-related services that are required, she added. Finally, she said, this grant could be also used for further modelling effective interventions for domestic financing, taking into account the results of the recent report of the AuTuMN project on the optimization of the strategic investments in TB in Bulgaria.

This article was originally published on

Transition and sustainability of HIV and TB responses in Eastern Europe and Central Asia

Report on the results of the “Technical consultation on transition to domestic funding of HIV and TB responses and their programatis sustainability in EECA” which took place in Istanbul on 21 – 22 of July 2015 and was organized y the Global Fund.

This report includes the presentation of Transition and Sustainability Principles and Draft Framework for Transition to Sustainability developed as an outcome of this consultation, and was discussed on September 29-30 , 2015 within the Regional Dialogue.

Transition and sustainability of HIV and TB responses in Eastern Europe and Central Asia (PDF)

The report was originally published by Eurasian Harm Reduction Network

Situation analysis of sustainability planning and readiness for responsible transition of harm reduction programs from Global Fund support to national funding in EECA

The report was prepared by David Otiashvili, M.D., Ph.D., between June and August 2015. The author collected and reviewed a range of background materials and gathered input from key informants familiar with the Global Fund projects in reviewed countries.

The desk review included analysis of country reports, program evaluation reports and data from international organizations. In-depth interviews with country respondents covered topics related to the progress of Global Fund funded programs, and the process of preparation for transition to domestic funding.

Key informants included fund portfolio managers (FPMs), recipients of Global Fund grants, members of Country Coordinating Mechanisms (CCMs), representatives of civil society organizations and key affected groups in 11 countries reviewed in this report.

The publication was prepared with generous financial support from the International Council of AIDS Service Organizations (ICASO). The views expressed in this publication do not necessarily reflect the donor’s official position.

Download report

The report was originally published by Eurasian Harm Reduction Network