Harm reduction programs in Europe were developed in the early 1980s of the 20th century and have come to be accepted today as an efficient model for protection of the rights and health of people who use drugs, hence as a model for efficient protection of public health. The first harm reduction program in Macedonia was developed in 1996, while today there are 16 similar programs in 13 different cities, financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria. A more detailed review of the development and importance of policies and programs for reduction of drug related harms was published in the previous issue of Drugs – Policies and Practices. This article deals with the sustainable continuity of the harm reduction programs once the finances allocated by the Global Fund to Fight AIDS, Tuberculosis and Malaria come to an end.
An agreement between the Government of the Republic of Macedonia and the Global Fund to Fight AIDS, Tuberculosis and Malaria, arranged the implementation of the project “Building a Coordinated Response to HIV/AIDS” from November 1st, 2004 to March 31st, 2008. The project developed into two new projects. The first one entitled “Keeping HIV Prevalence Low in Macedonia – Scaling-up and Focusing Interventions” was implemented from April 17th, 2008 to March 3rd, 2013, and the second entitled “Keeping HIV Prevalence Low in Macedonia – Scaling-up and Focusing Interventions and Using an Integrated and Community Oriented Approach to ensure sustainability of services and uninterrupted implementations of preventive interventions among ‘MARPs,’” implemented from January 1st, 2012 to December 31st, 2016, the closing date stipulated with the agreement for financing the activities with the amount granted by the Global Fund to Fight AIDS, Tuberculosis and Malaria. Harm reduction programs are a significant share of the three mentioned projects, hence the concerns regarding their future continuity are founded.
According to the announcements, after a 20-year support the Global Fund to Fight AIDS, Tuberculosis and Malaria expects the Government of the Republic of Macedonia to undertake the obligations and ensure the continuity of the activities for sustaining HIV low prevalence. Since the projects are soon coming to an end, the Platform for sustaining the HIV services, part of whose members are the organizations that implement the harm reduction programs, has growing concerns regarding the future sustainability of the activities for HIV/AIDS prevention. Truth to be told, in August 2014 the Ministry of Health began the process for establishing the criteria for certification of the organizations to be financed starting from 2017, however until the release of this issue there were no visible guarantees that the Ministry was prepared to continue the financing of the project activities.
Opportunities for financing the harm reduction programs from the budgets of the Ministry of Health and the Ministry of Labour and Social Politics
The estimation for the expenditures within the harm reduction programs shows that the annual budget for sustaining all 16 harm reduction programs is somewhere between 27,391,500.74 MKD and 34,853,928.62 MKD, depending on the financing model.
HOPS’s 2014 budget monitoring of the Ministry of Health’s two programs and one program implemented by the Ministry of Labour and Social Politics, the most convenient ones to cover the financing of the harm reduction programs, gives little hope as to providing sustainable financing for these programs.
Namely, we sent requests for free access to public information to the beneficiaries and implementers of the Program for health protection of people with dependence disorders in the Republic of Macedonia, the Program for protection of the population against HIV/AIDS and the Program for social care – Day centres and shelters for extra-institutional social protection, requesting information about bank statements, accounting cards and invoices for 2011, 2012 and 2013. Although we expected quick responds from the institutions, considering the requests were made as easy and understandable as possible, the monitoring proved to be a long and painstaking process of constant communication in order to realize the right to free access to public information. The selective answers to the requests or the silence from certain implementers of harm reduction programs limits the insight into the budgets’ expenditures, thus rendering more difficult a factual assessment of the opportunities for sustainable financing of these programs.
The limited data showed that the Ministry of Health is inconsistent in its obligations towards the implementers of the Program for health protection of people with dependences disorders and the Program for protection of the population from HIV/AIDS, specifically claims paid directly from the Budget of the Republic of Macedonia. Contrary to this, the Ministry of Health is more consistent in the financial obligations towards the implementers whose activities are financed from the project “Keeping HIV Prevalence Low in Macedonia – Scaling-up and Focusing Interventions and Using an Integrated and Community Oriented Approach to ensure sustainability of services and uninterrupted implementations of preventive interventions among ‘MARPs.” Still, as was aforementioned, the project is financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria which insists on consistent implementation of the agreed obligations.
It was very difficult to assess the Budget of the Program for social protection – Day centres and shelters for extra-institutional social protection. The Ministry of Labour and Social Policy informed us that no separate data can be provided on the two Day centres for drug users and members of their families in Kumanovo and Ohrid, active in 2011, 2012 and 2013. The Centres were active within the Inter-municipal centres for social work and no separate records were kept for them. The Day center in Kumanovo hasn’t been active for two years, the space is empty and in a bad shape, while the Day centre in Ohrid has been renovated for the last few months and is expected to be active soon. Still, the available data shows that on average only 0.73% were allocated from the Program’s budget for the Day centres in 2011, 2012 and 2013, or around 7,020.00 MKD per client a year. Of course, the Program surely allows for more finances for people who use drugs, particularly considering the fact that, according to the 2010 estimation of the Public Health Institute, there are around 10,200 people who inject opioids in Macedonia, not counting the people who use other types of drugs. The idea is to offer services like information, counselling and education, employment opportunities, cultural and recreation activities, in addition to implementing harm reduction policies in the Day centres for drug users and members of their families.
Perspectives on stable sustainability of harm reduction programs
Lacking detailed data on the budget expenditures, we can only presume that the Ministry of Health would find a way to provide the finances now granted by the Global Fund to Fight AIDS, Tuberculosis and Malaria. This would ensure the continuity of harm reduction programs, financed within the Program for protection of the population from HIV/AIDS. If this proves impossible, harm reduction programs would have to be maintained with another solution, perhaps a new inter-ministerial program financed by two or more ministries.
Regardless, the Government of the Republic of Macedonia is expected to comply with its obligation towards the Global Fund and continue the financing of HIV/AIDS prevention activities. What concerns us is how this would be conducted.
The Budgets’ monitoring showed that the Ministry of Health’s payments regarding its financial obligations to the implementers of the monitored programs are incomplete and with big delays. It is unclear how the implementers manage to supply the unpaid claims. The persons in charge briefly explained that parts are covered with the finances allocated for other health services, unrelated with the monitored programs. However, these finances are insufficient and generate debts towards the creditors while the quality of the services offered decreases.
Services offered within harm reduction programs cannot be charged for nor are they designed to be so, hence their existence is conditioned by the timely and complete payments. The success of the programs is based on the clients’ trust, earned with sincere dedication. It is this trust that makes harm reduction take on a role of mediators between people who use drugs and institutions. A decrease in quality would alienate clients from harm reduction programs and create a bigger gap between the community and the institutions, which would lead to less efficient prevention of HIV/AIDS, Hepatitis B and C and other blood borne and sexually transmitted infections.
Considering the institutional silence and lack of willingness to solve essential social and health issues we can only hope that the competent institutions would find a solution for stable sustainability of harm reduction programs. A possible solution would be to recognize the organizations that implement harm reduction programs as partners of the line ministries. This would provide democratization of the decision-making process and control over the efficiency of HIV/AIDS prevention. In addition, these organizations can contribute by helping the line ministries provide the additional finances from other sources for further development and extension of harm reduction programs.
The author is a program assistant at CEDR – Centre for Education, Documentation and Research at HOPS – Healthy Options Project Skopje. He has a Master’s degree in Ethnology and Anthropology and long research experience with different socially marginalized groups/communities, particularly people who use drugs.